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OBSTETRICS, 



BY 



CHARLES D. MEIGS, M.D 



OBSTETRICS: 



THE 



SCIENCE AND THE ART 



BY 



CHARLES D. MEIGS, M. D., 

professor of midwifery and the diseases of women and children in the jefferson medical 

college at philadelphia j one of the physicians to the lying-in department of the 

pennsylvania hospital; vice president of the philadelphia college of 

physicians: member of the American philosophical society ; 

of the american medical association. etc. etc 



77TTH ONE HUNDRED AND TWENTY-ONE ILLUSTRATIONS. 




PHILADELPHIA: 

LEA AND BLAN CHARD, 

1849, 






Entered according to the Act of Congress, in the year 1849. by 
LEA AND BLANCHARD, 

in the Clerk's Office of the District Court for the Eastern District of Pennsylvania 



PHILADELPHIA: 
T. K, AND P. G. COLLINS, PRINTERS 



TO THE 



EMINENT WESTERN PHYSICIAN, 



PHILOSOPHER, 



GENTLEMAN AND SCHOLAR, 



DANIEL DRAKE, 



CINCINNATI 



A LETTER. 

My Dear Sir : 

As I have taken the liberty to inscribe this work with your name, 
which I never pronounce without a feeling of affectionate respect, I 
desire to say a few words to you in explanation of my views and 
wishes in regard to the volume. 

You may haply be aware, that I caused to be printed some years 
since, a small volume, entitled the " Philadelphia Practice of Mid- 
wifery:" a second edition in octavo form, and somewhat enlarged 
and amended, has now been for a considerable time exhausted ; and 
although I have had proposals to publish a third edition of the Treat- 
ise, it has not been convenient for me to undertake the labor until 
the early part of the past summer. 

Upon completing my arrangements with the Publishers, and com- 
mencing the task, I Was induced to re-cast and re-write a great part 
of the work ; in which I did not reject wholly the fruits of my studies 
in earlier years. 

This Treatise is so different from the former, that I conclude I have 
a just right to present it to you as a new one ; and accordingly have 
adopted a new title, as you will have seen. 

I have addressed it to the Student, and it is to him that I speak in 
every page. I have done this because I was not to presume to instruct 
those who know as well, or perhaps better than I, every point of duty 
appertaining to the vocation of the accoucheur, both as to the Science 
and the Art. I was well aware that there are many of my brethren 
in this country who relate their experience, and explain the rationale 
of all the Art and Science of Obstetricy to their classes in our nume- 
rous medical schools; and I had no pretensions to know more upon 
these subjects than they, nor to instruct them. Induced by these views, 
I have been, perhaps, too elementary in some parts of the work, and 
addressed the Student only ; but I hope it will be found that the explana- 
tions I have given may serve to remove difficulties from the track of the 



Vlll A LETTER. 

medical student, while they may also lend facilities to the progress of the 
younger and not much experienced practitioner. I thought that young 
accoucheurs, who, in the distant and thinly settled parts of the country, 
should require a consultation where time and opportunity would not 
allow of it, might find herein the needful counsel and explanation, 
and that it would be for me a great happiness to be useful in such 
emergencies. Hence I have entered into many particulars, and even 
trivials, that are not commonly set down in the books. 

As to the scientific part of the work, I may say that I hope it will 
be useful to the Student. If I have succeeded in exhibiting just views 
in that department, my labor cannot be without fruit; since it is only 
by such means that the vocation of the Surgeon-accoucheur can be- 
come an elevated one. It is the science of the practitioner that raises 
him immeasurably above the dextrous midwives of the land, whose 
dexterity indeed does not prevent their ignorance from rendering them 
unsafe depositories of such important interests as those that concern 
the conservation of our wives and daughters, and their little children. 
An accoucheur who is merely dextrous, and who is not acquainted 
with the scientific parts of his profession, may be in a manner superior 
to the midwife ; but he is in some regards inferior, since his sex is 
an objection to his employment which ought to be waived only in 
consideration of his Scholarship. 

I have in all this treatise endeavored, upon suitable occasions, to 
inculcate good motives. — Good and pure motives are essential to the 
honorable estimation of this department of Medicine and Surgery. — 
I believe that the sentiments of good Monsieur Viardel, on these points, 
are very just, and I shall take leave to cite the following fragments 
from his book at p. 261. M. Viardel, who was in full practice at 
Paris about 1670, in speaking of the Accoucheur, says — 

" II doit etre propre dans ses habits, mais toutes fois vetu modeste- 
ment, et non en fanfaron, *********** [\ doit de plus etre 
doux dans ses paroles, et agreable dans sa conversation * * * * 
mais surtout, il doit etre prudent et discret: prudent a dresser son 
prognostic, et a prevoir ce qui doit arriver, de peur de n'encourir le 
blame des assistans. II doit etre discret, et ne point reveler le secret 
qu'on lui aura confie. * * * * En un mot, il doit etre patient pour 
ne pas se rebuter, humain et charitable, surtout envers les pauvres, 
et n'agir pas dans son travail pour le lucre et son interet propre, mais 
comme dit PApotre, pour Phonneur et la gloire de Dieu et pour conser- 
ver sa reputation parmi le monde." 



A LETTER. IX 

Like all books, mine has some iterations; but I thought that to make 
my pages useful, it was inevitable to make repeated statements ; without 
which, I could not inscribe the why and the how on the same pages. 
If this is fit to be a book of consultation, it will be more useful for this 
fault. Hippocrates says that art is long: — I think that to repeat, is 
really to abbreviate; for the y Ss tezvy H- ax P% and the *; 8s xpiois ^cas*^, 
both vanish under a clear and comprehensible delineation of the Why 
and the How for every special occasion. 

I think you will find that I have given in this book a very clear 
relation of the new doctrines of menstruation, and that I have shown 
the Student the whole history and progress of the discovery of the 
mammiferous ovulum from the time of the detection of the germinal 
vesicle by the Breslau professor, down to the last, most complete and 
admirable exposition of the whole subject by M. Coste, of the College 
of France. If this part of my publication is full and clear, I cannot 
doubt of its being advantageous. If I have done but this, and 
no more, I shall look confidently for useful results to my labor. For 
I know that multitudes of the younger class of my medical brethren, 
and especially of those that still belong to the Student-class, are grossly 
neglected as to their instruction in these particulars. No one should 
be sent forthwith a diploma certificating his acquaintance with all the 
branches of Medicine, whereas his therapeutical course while unin- 
formed on the questions referred to cannot but be a mere succession of 
conjectures and blunders rather than the sure steps of a learned and 
accurate reasoner. 

Apologetically, I pray the reader to know that the labor of this 
writing and publishing, added to my professional vocations, has been 
so severe as seriously to affect my health — to that degree, indeed, that 
I have been compelled to finish it by the assistance of an amanuensis, 
who has written at my dictation and read the proof sheets. I have not 
dared to examine the proofs of the last 250 pages on acccount of a 
distressing neuralgia of the eyes, which has also prevented me from 
reading any book or considerable pamphlet since the autumn. 

It may be that I ought to solicit from my American brethren, a 
favorable acceptance of this work, the fruit of many years of painful 
toil in the acquisition of clinical experience and knowledge. I abstain 
from doing so, not because I desire not such acceptance, but only upon 
the certain conviction I have, that the book is no longer mine — and 
that in going forth from my hands, it hath found many owners, each 
of whom will and ought to treat it as may seem good in his own sight. 



X A LETTER. 

As for you, my dear friend, I invoke your favorable construction of 
my design and action in publishing this treatise ; and I pray you to 
believe that I am, with the greatest sincerity, your most obedient and 
most faithful servant and attached friend, 

CH. D. MEIGS. 

Phiiaba. : Feb. 1S49. 

To Dr. Drake, 

Pnor. of the Pract. or Mee.. Unto, of Louisville. Ken. 



CONTENTS 



PAGE 

17 Preliminary observations. 

18 Classification of the subjects. 

19 Cuvier's notion of a method. 



PART I. 

ANATOMY OF THE PARTS CONCERNED IN THE ACTS OF REPRODUCTION. 

CHAPTER I. 

OF THE PELVIS. 

22 Fig. 1. Of the pelvis. 

22 Upper and lower pelvis divided by the linea ileo-pectinea or strait. 

22 The straits. 

23 The excavation. 
23 Coxal-bones. 

23 Measurement of a pelvis. 

24 Fig. 2. A transverse section of pelvis, back view. 

24 Fig. 3. A transverse section of pelvis showing the pubal arch. 

24 Description of the arch. 

25 Form of superior strait, as in Fig. 4. 

25 Form of perineal strait, as in Fig. 5. 

26 Notices of the pelvic ligaments. 

26 Relation of foetus to the straits and excavation. 

27 Fig. 6. Showing the flexed state of the foetus in utero. 

27 Particular description of sacrum. 

28 Fig. 7. The sacrum. 

28 The sacral foramina. 

29 Case showing the effects of pressure on the sacral nerves. 

30 Case of forceps operation for pressure on the sacral nerves. 

31 The coccyx described. Fig. 8. 



Xll CONTENTS. 

PAGE 

32 The sacro-iliac junction. The sacro-Yertebral angle. Fig. 9. 

32 The right os innoniinatum. Fig. 10. 

33 Division of the os innominatum at the acetabulum, with Fig. 11. 

34 Auricular facette of the innominatum — the pubal facette — sacro-sciatic 

notch — plane of the ischium. 

35 Os pubis. Fig. 12. 

36 Os pubis — or bar-bone. Fig. 13. Symphyseal ligaments. 

37 Fig. 14, with account of pelvic ligaments. 

38 Opening of the pelvic joints — cases of relaxed symphysis. 

39 The whole pelvis — plane of the strait — its inclination. 

40 Fig. 15. Inclination of the plane of the strait. 

41 "Wigand's figures, 16, 17, of the inclination of the straits. 

42 Wigand's figures, 18, 19. 

43 Plane of inferior strait. Fig. 20. 

44 Diameters of pelvis. Fig. 21. 

45 Ten pelves measured. A table. 

46 Table of diameters from authors. 

46 Axis of pelvis. Fig. 22. 

47 Carus's curve, with Fig. 23. 

48 The recent pelvis. Fig. 24. 

49 Reflections of the pelvic peritoneum — recto-vaginal peritoneal cul de 

sac — muscles within the pelvis — blood-vessels, &c. 

50 Fig. 25. Contents of pelvis. 

CHAPTER n. 

MECHANISM OE THE PELVIS — MECHANISM OF LABOR, AS IT DEPENDS 
UPON THE RELATIONS OF THE PELVIS AND THE FffiTAL HEAD. 

51 Flexion, and obliquity of the head. Fig. 26. 

52 Dip of the occipito-mental diameter in vertex labor — rotation. 

53 Extension illustrated by Fig. 27 — Influence of the perineum in causing 

extension of the head — restitution. 

54 Rotation of the shoulders to the pubis, in vertex labors — mechanism 

of second position. Fig. 28. 

55 Mechanism of third position. 

56 Fourth position. Fig. 29. 

57 Fig. 30. Showing that when the vertex in fourth position cannot 

come to the pubis, the occipital extremity of the occipito-frontal 
diameter must escape first — fifth position. Fig. 31. 

58 Sixth position — a case related — an occipito-posterior position, in which 

the restitution earned the vertex back to the sacrum. 

59 Face presentations. Figs. 32, 33. 

60 The doctrine in face cases — bring the chin to the pubis. 



CONTENTS. Xlll 



CHAPTER III. 

OF THE CHILD'S HEAD AND OTHER PRESENTING PARTS. 
PAGE 

61 Fig. 34. Representing a foetal cranium. 

62 Figs. 35, 36. The foetal head. 

63 Dimensions of the head. 

64 Occipito-mental diameter 5.6; occipito-frontal 4.10; bi-parietal 3.11; 

fontanels. 

65 Presentations — Fig. 37. Illustration of vertex presentations in first 

position. 

68 Two presentations — cephalic and pelvic. Figs. 38 ; 39. 

69 Position of a presentation. 

70 Six vertex positions — four pelvic positions — four shoulder positions. 

CHAPTER IY. 

THE ORGANS OF GENERATION. 

72 Pudenda — Vulva — Labia. 

73 Labial thrombus — oedema labiorum. 

74 Labial abscess. 

75 Cohesion of the labia. 

76 Differences of the labia — nymphae, 

78 Clitoris. 

79 Urethra and vestibulum. 

80 Hymen. 

81 Fourchette — perineum. 

83 Laceration of perineum. 

84 Vagina — prolapsus uteri is a disease of the vagina, 

86 Prolapsus vaginae. Fig. 40. 

87 The womb. Fig. 41. 

88 The womb. Fig. 41. Structure and power of the womb, 

90 Fig. 42. The muscularity of the womb. 

91 Action of the womb in labors — duration and number of pains. 

CHAPTER Y. 

THE OVARIES DESCRIBED, 

94 Stroma of ovaries. Graafian cells. 

95 Fig. 44. Magnified ovulum. Membrana granulosa. Macula germi- 

nativa. 

96 De Graaf. 



XIV CONTENTS. 

PAGE 

97 Purkinje's account of the vesicle. Figs. 45, 46, 47. 

98 Yon Baer's Epistle de Ovi Manimalinni, &c. 

100 M. Coste. — Hist. Gen. et Partic. du Developpenient, &c. Wharton 
Jones and Wagner. 

102 Coste's dissection of ovary. Fig. 48. 

103 Wagner's human ovule. Fig. 49. 

104 M. Burdach and M. Huschke cited. 

105 Corpus luteuni. Fig. 50. 



PART II. 

THE PHYSIOLOGY OE REPRODUCTION. 

CHAPTER VL 

MENSTRUATION. 

119 Analyses of menstrua. 

121 View of the ovaries in menstruation. Fig. 51. 

125 Express doctrine of menstruation. 

126 Menstruation is ovulation. 

129 Time in which fecundation is possible. 

chapter vn. 

CAUSES AND TREATMENT OF AMENORRHEA. 

140 Emansio mensium. 

141 The endangium or blood-membrane. 

143 Anaemia of emansio. Drugs. 

144 Iron. Yallet's mass. 

145 Blaud's pill. Quevenne's iron. 

CHAPTER Yin. 

PREGNANCY. 

148 Definition of pregnancy. 

149 Fecundation. 

150 Conception. 

154 Decidua. Figs. 52, 53. 

156 M. Coste's views of the decidua. Fig. 54. 

158 Decidua of Didelphis. Figs. 56, 7. 



CONTENTS. XV 

PAGE 

162^ Gradual development of gravid womb — its effects. 

167 Quickening. 

171 Placenta. Hunter, Velpeau, Flourens, Owen. Human placenta. Figs. 
57, 58. 

176 Placentules of the ruminants. 

177 Appearances seen on detaching placenta in the subject. 

179 Blastoderm. 

180 Allantois. 

181 Umbilical vesicle. 

182 Omphalo-mesenteric vessels and cord. Fig. 60. 
184 Circulation of foetus. 

188 Faulty developments. Teratology. Figs. 61, 62, 63, 64, 65. 

193 Duration of pregnancy. Tables of. 

199 Computation of term. 

200 Changes in the nature of the womb. Fig. 66. 
202 Uterine muscles. Fig. 67. 

204 Obliquity. Pressure on the vessels. 

207 Anaemia Gravidi. Hydatids. 

210 Moles. Physometra. Hydrometra. 

211 Abortion. 

215 Dewees' placenta hook. Bond's forceps. 

216 Tampon. 

219 Prolapsus. 

220 Betroversion. Fig. 70. 
236 Extra-uterine pregnancy. 
238 Signs of pregnancy. 



PART III. 

THE THERAPEUTICS AND SURGERY OE MIDWIFERY. 

CHAPTEB IX. 

LABOR. 

246 John Ocularius and Al-Mamun. 

247 Citation from Wigand, G-eburt des Menschen. 

248 M. Quetelet's statistics of labor. 

249 Definition of labor. 

250 Cause of labor. 

251 Subsidence of the womb. 

252 Labor pains. 



XVI CONTENTS. 

PAGE 

256 State of cervix uteri dilated. Fig. 71. Constitutional effects of the 

pains. 

257 Outward signs of labor. 

258 Touching. 
260 False-pains. 

263 Periodicity of labor-pains. 

264 Progress of the contraction in the whole womb. 

266 Extrusion of the placenta. 

267 State of the foetus, in labor. Outward thrust of the spinal arch under 

the pains. 

268 Positions. Fig. 72. 

270 Madame Boivin's table of positions. 

271 Dr. Nsegele's Lehrbuch der G-eburtshiilfe. 

272 Observations on the mechanism of the labor, 
274 State of the patient soon after delivery. 
276 Lochia. 

CHAPTER X. 

CONDUCT OF A LABOR. 

279 Table of duration of labors. 

281 Cautions relative to the circulation during labor, 

284 Alvus. 

285 Decubitus. 

287 To assist the flexion and rotation. 

288 To correct obliquity. 

289 Vaginal vesicocele; case of, in a labor. 

291 Management of the cervix and os uteri, Effects of a bad sacrum, 

292 Influence of a badly shaped pubis. 

293 The perineum. 

295 Cord around the neck. The shoulders. 

296 How to treat the child, 

297 The placenta. 

298 Retained placenta. 

299 Hour-glass contraction, 

302 Womb after delivery, 

303 After-pains. 

304 Hemorrhage. 

307 Sitting up too soon. 

309 Tampon never, in labors, 

310 Turn out the clot. Binder 

312 Diet. 

313 Suckling. Medicine. 

314 Lochia. Sitting up. 



CONTENTS. XV11 

PAGE 

315 Etherization. 

319 Professor Simpson's Letter. 

322 Reply to Professor Simpson's Letter. 

CHAPTER XI. 

FACE PRESENTATION. Fig. 73. 

329 Fig. 74. Fig. 75. 

330 Fig. 76. Fig. 77. 

338 Fig. 78. Chin to sacrum in face-case. 

CHAPTER XH. 

PRESENTATION OF PELVIC EXTREMITY OF THE CHILD. 

345 Causes of pelvic presentations. 

348 Fatalities in breech cases. Diagnosis of them. 

350 Not to bring down the feet. 

352 Fig. 79. Fig. 80. Illustrations of pelvic presentations. First position. 

354 Second position. Third position of breech. 

356 Fourth position. 

CHAPTER XIII. 

PRETERNATURAL LABORS — CAUSES. 

362 Madame Lachapelle's statistical table of labors. 

363 Shoulder presentations. 

365 Two shoulder presentations for each shoulder. Fig. 82. Diagnosis. 

366 Turning in shoulder cases. 

374 Spontaneous evolution of the foetus. 

375 Fig. 83. Of double-headed child and of anencephalous child. Fig. 

84, to illustrate spontaneous evolution. 
377 Hemorrhagic labors. 
382 Placenta praevia. 

389 Concealed hemorrhage. 

390 Post-partum hemorrhage. 
392 Hour-glass contraction . 

394 Hemorrhage after delivery of the placenta. 

397 Mauriceau's account of his sister's case. 

401 Convulsions. 

412 Cramp. Prolapse of the cord. 

414 Fainting. Hernia. Anaemia. 

421 Exhaustion. 

426 Engagement of bowel in front of womb. 
1 



XV111 CONTENTS. 

PAGE 

427 Carcinoma Uteri. Illustrated by Figs. 85, 86, 87. 

431 Variola as cause of preternatural labor. 

432 Vaccination of the gravid woman dangerous. 
434 Twins and triplets. Fig. 88. 

439 Management of preternatural labor. Fig. 89. 

440 Turning. See Figs. 90 to 100. 

CHAPTER XIV. 

DEFORMED PELVIS. 

454 Deformed pelvis. Figs, of, 101 to 106. 

459 Mensuration of the pelvis. Figs. 107, 108. 

462 Fig. 109, illustrative of descent of bladder in labor. 

464 Laceration of womb and vagina. 

CHAPTER XV. 

THE FORCEPS. 

468 History of tbe discovery and progress of the forceps. 

471 Mauriceau's relation of Hugh Chamberlen's operation. 

473 Chamberlen's preface. 

477 The Chamberlen instruments. Figs, of, 110 to 114. 

480 Smellie and Levret. Manni's criticism. 

481 Pean's and Baudelocque's forceps. 

482 Professor Davis" forceps. 

484 Professor Huston's forceps. Fig. 115. 

485 Davis' forceps applied to head. Fig. 116. 

486 Appropriation of obstetrical instruments — as mother's or child's. 
417 to 560 Directions as to use of forceps. 

CHAPTER XVI. 

EMBRYOTOMY. 

516 Mrs. R.'s case. 

526 Author's embryotomy forceps. Figs. 118, 119, 120. 

531 A case of Cesarean operation. 

CHAPTER XvH. 

INDUCTION OF PREMATURE LABOR. 



CONTENTS. XIX 

CHAPTER XVni. 

INVERSION OE THE WOMB. 
PAGE 

552 Dr. Hatch's letter to author, describing a case of inversion. 
556 Notice of Mr. Crosse's work on Inversion. 

CHAPTER XIX. 

PUERPERAL FEVER. 

CHAPTER XX. 



OP ATRESIA VAGINA. 

583 Case of atresia after labor, in which the uterus was punctured from the 

rectum. 
586 Case of atresia vaginae. 

CHAPTER XXI. 

ON ERGOT. 

CHAPTER XXII. 

OF MILK-FEVER. 

599 Inflammation of the breast — sore nipples. 

603 Weed. 

605 Gathered breast. 



PART I V. 

THE HISTORY AND DISEASES OF THE YOUNG CHILD. 

CHAPTER XXIII. 

611 Viability of the child — establishment of the respiratory life. 

612 Non-viable child. 

613 Tying the navel string. 

614 Washing the child. 

615 Dressing the navel — dress for the child. 
618 Food of the neonatus. 

624 Fall of the navel string, and formation of umbilicus. 

625 The meconium. 



XX CONTESTS. 

PAGE 

626 Alrine dejections. 

629 The gum. 

630 Sore-mouth. 

632 Jaundice— Coryza, or snuffles. 

CHAPTER XXIV. 

CYANOSIS NEONATORUM. 

CHAPTER XXV. 

667 Supplementary. 

669 Bond's instrument for retroversion. 



OBSTETRICS 



PRELIMINARY OBSERVATIONS. 

Midwifery is the art of assisting women in labor. 

Obstetricy comprises the sciences of anatomy, physiology and pa- 
thology, as relative to the reproductive organs, and the arts of thera- 
peutics and surgery, as applied to sexual affections in women. 

Midwifery is an Art. 

Obstetricy is a Science. 

A Midwife or Accoucheur is one who assumes the conduct of cases 
of labor. 

An Obstetrician is a physician, who, in addition to a general know- 
ledge of physic and surgery, adds the special information that is 
necessary for one having the peculiar charge of all sexual affections, 
whether in the department of Midwifery proper, or in other complaints 
of the sex. 

Notwithstanding obstetricy is constituted of several different 
branches or sorts of knowledge, it claims to be considered as a 
distinct science. 

This claim it could not set forth nor maintain, until, in a modern 
age, a method or classification of the items of which it consists, has 
been with some success attempted. 

The writings of the ancients, whether the Greeks, Romans, or 
Arabians, upon obstetrics, deserve not to be held as scientific works; 
nor do the productions of Pare, Guillemeau, Lamotte, Mauriceau or 
Deventer, merit so high a rank. 

Of the English writers, neither Thomas Rainald, Chapman, Gif- 
fard, nor Burton, rise to the elevation of scientific authors; whereas, 
Smellie, Denman, David D. Davis, Collins, Dewees, Robert Lee, 
Churchill, and many others, have produced works whose scientific 
pretensions cannot be denied. It is, perhaps, unnecessary in this 
conjuncture to name the names of Levret, Baudelocque, Gardien, Vel- 
peau, Wigand, Nsegele, Jdrg, Stein, Carus, Lowenstein, and many 
2 



18 PRELIMINARY OBSERVATIONS OBSTETRICS A SCIENCE. 

other French and German philosophers who have treated of our sub- 
ject with an order, precision, clearness and dignity, that place its 
claims to be regarded as a science beyond cavil. 

While I contend for the claim of obstetricy to be regarded as one 
of the sciences, I admit the difficulty of discovering a perfect method 
or classification of the items of knowledge that compose the sum of it; 
and, perhaps, it may be contended that a method is essential to the 
nature of a science. It may be that it is not a science, but only a 
collection of items of disjointed sciences. The difficulty consists in 
the distinctness and absolute isolation of many of the facts or integers 
of the science, and the want of any natural order or series in them ; its 
items being rather fitted to be gathered together in a set of collections 
or fascicles, than in a regular sequence of books or chapters. What 
methodical connection is there, in fact, between a chapter on retro- 
version of the womb and one on the history and application of the 
forceps ; or what alliance betwixt the sacro-sciatic ligaments, and a 
crural phlebitis, or a mammary abscess? 

In zoology there is a scale or gradation of the integral items of 
the science, resting on the constitution of the nervous mass of the 
different classes as well as the species. In mathematics, or the science 
of numbers, there is also a gradation, a scale, or regular series, all 
the integers of w T hich have a relation to each other. 

There is, however, in obstetricy, a Method of the several subjects 
of contemplation that may serve to indicate to the learner or student 
the place in which he ought to find the special object of his search. 

I am fully persuaded that we have, in our branch, no natural method ; 
and, therefore, without seeking for novel divisions and classifications 
to be used in this work, I propose the following course or order of 
studies. 

I shall treat of — 

I. The anatomy of the parts concerned in the acts of reproduction, 
with remarks on their pathology and therapeutics. 

II. The physiology of reproduction. 

III. The therapeutics and surgery of midwifery, or the obstetric art. 

IV. The history and diseases of the neonatus, or young child. 
Here it seems are four divisions, classes, or branches of obstetricy; 

each one of which is susceptible of being treated in a separate book, 
or volume. But, in order to the greater convenience of the reader, I 
shall prefer to transpose, according to my own pleasure or my own 
views of what may most conduce to the easy and rapid progress of the 
student, the various facts, precepts and doctrines, from one depart- 



PRELIMINARY OBSERVATIONS METHOD IN OBSTETRICS. 19 

ment to another, without rigorous reference to an order or method. 
The above arrangement shows that our obstetricy is a science, in so far 
as a method is necessary to that title ; for it is clear that by dividing 
the subjects of this volume in the manner now mentioned, we have 
it in our power to reduce to classes, genera and species, the various 
topics or facts to be exposed — and thus, with proper painstaking, 
to make of this book a kind of ledger, in which shall be found posted 
up, at page and line, all the particulars that we may deem it proper 
to enter on the pages. 

M. G. Cuvier, in the Introduction to the Regne Animal, says, 
" There can be only one perfect method, and that is a natural me- 
thod. This is the title given to an arrangement, in which, beings 
of the same genus are placed nearer to each other than to beings 
of any other genera, those of the same order nearer together than to 
those of other orders, and so throughout the arrangement. This 
is the ideal method to which everything in natural history should 
tend; for, it is evident, if it could be attained, we should be in pos- 
session of an exact and complete expression of all nature. In a word, 
a natural method would be the whole science; and every step towards 
it carries the science nearer to perfection." 

Experience teaches that even in Natural history, an exact and per- 
fect method has not yet been attained. Nevertheless, so great have 
been the improvements in method, that naturalists have little embar- 
rassment in mastering the multitudinous items of which their science 
consists, in comparison with our difficulty of arriving at certain con- 
clusions in a branch of knowledge or science in which is mixed up 
with a pure natural history, an unspeakable vastness of psychological 
and metaphysical cognitions. 

Inasmuch as all the particular items of obstetrical knowledge must 
have an ultimate reference to the anatomical structures concerned in 
reproduction, I shall, following the custom of the moderns, commence 
with the osteological part of our anatomy, and proceed at once to 
describe the obstetric pelvis — or the female pelvis. 



PART I. 

ANATOMY OF THE PARTS CONCERNED IN THE ACTS 
OF REPRODUCTION. 



CHAPTER I. 



THE PELVIS. 



The Pelvis is a bony canal, or passage through which the child is 
thrust in labor, and which encloses and protects the internal organs 
of generation. 

The internal form and the dimensions of the pelvis, in all the mam- 
miferous quadrupeds, are conformable to the shape and magnitude of 
the fcetus that is destined at term to be transmitted through the canals 
or passages in question; and, as any want of such conformableness 
may impede or prevent the accomplishment of the act of parturition, 
it is of the highest moment to the patient that the obstetrician should 
be accurately informed upon all the particulars both of the pelvis and 
the foetus, as related to each other in midwifery. 

Further, as the genital organs, both external and internal, are 
attached to, and supported and protected by, the osseous pelvis, and 
as both they and the child are liable to injury from the resistance of 
the solid bone against which they are compressed, no accoucheur 
ought to be held competent to have charge of cases in midwifery who 
has not previously given due attention to the study of the pelvis. 

The exterior surface of the pelvis belongs to the province of the 
anatomist and surgeon : it is only with the interior aspect of it that 
the accoucheur is interested. 

By the Greeks, it was denominated Tts-Kvr, by the Romans, pelvis ; 
the Italians call it il bacino; the Spaniards, el pelvis; the French, le 
bassin; the Germans, das beckens. 



22 



THE PELVIS — STRAITS. 



i 



Fig. 1. 




In all these languages, in speaking of the pelvis, the idea of a bowl 
or basin is expressed. 

I annex a cut which represents the pelvis, and which shows the 
supposed resemblance to a basin or bowl. 

The resemblance is a very forced one, and is lessened by observ- 
ing that the bottom is broken or wanting, which is the case also as 
to a large portion of the front edge or side both above and below. 
Admitting, in accordance to custom, that the pelvis is a basin, 

it is seen that the up- 
per part consists of a 
segment of a larger 
sphere than the lower 
part. 

This difference has 
led to the division of 
it into the upper and 
lower, the greater 
and lesser, and the 
false and true pelvis, 
or basin. 

This division is 
found to be at a line or ridge, called the linea ileo-pectinea, a raised 
line or bead, that, commencing in front, and passing backwards, left 
and right, runs from the pubis, in front, to the top of the sacrum on 
the back part of the basin. The top of the sacrum is the part upon 
which the lowest lumbar vertebra or segment of the back-bone rests. 
This linea ileo-pectinea, which serves to contract the pelvis, is the 
boundary betwixt the true and false pelvis. It constitutes the supe- 
rior strait; and an imaginary superficies, bounded by it, is the plane 
of the superior strait. All that part of the pelvis that lies above this 
plane, is the upper basin; whereas, all that is below it, is the true 
pelvis, the excavation, the cavity. I shall commonly speak of it as 
the Excavation. 

The word strait, in this connection, means narrows, stricture, con- 
traction; and it is truly a narrows, inasmuch as the superior basin 
widens hence upwards, while the pelvis in the excavation is more 
capacious, or of greater diameter than it is at the narrows. 

The superior strait is also, by some writers, denominated the en- 
trance, the inlet, or the abdominal strait; and this, in contradistinc- 
tion to the inferior strait, the outlet, or perineal strait, which is also a 
narrows. 



THE PELVIS UPPER AND LOWER BASINS. 23 

Thus, it is seen that the female pelvis, like an hour-glass, is con- 
tracted in the middle. 

A child, to be born, must pass down from the upper pelvis, through 
the superior strait, into the true pelvis or excavation ; when it has been 
subjected, in the excavation, to certain changes of position, by means of 
the mechanical power of the bony walls thereof, it is next driven out 
of the true pelvis, passing through the inferior or perineal strait. In 
like manner, a ship, sailing on the Black Sea, may pass the Strait 
of the Dardanelles into the capacious Mediterranean, from whence it 
passes, through the Strait of Gibraltar, into the great ocean. 

A pelvis consists of two coxal or hip-bones, a sacrum, and its ap- 
pendix, the coccyx. 

The wide upper basin is composed of the expanded concave plates 
of the coxal bones, which are so fashioned as to leave, in a skeleton, 
the appearance of a deficiency in the front edge of the bowl. This 
deficiency is supplied, in the recent or living subject, by the tendons 
of the oblique muscles, by Poupart's ligament, and by the recti and 
pyramidales muscles. 

The deficiency is made up behind by the lumbar vertebras which 
rise upwards betwixt the posterior edges of the coxal bones. 

The soft tissues that supply the defect in front, admit of changes 
then, in the shape of the bowl which is ductile there; while it is firm 
and unyielding posteriorly and upon the sides, which consist of solid 
bone. 

The lower, or true pelvis, is composed of the sacrum and coccyx 
behind; a portion of the ilium and the ischium, on the sides; and 
the pubis, in front. Each coxal bone is made up by the union of the 
ilium, the ischium, and the pubis. 

The superior basin, in a fine specimen now before me, Fig. 1, 
measured transversely at the highest part, is 9.5 inches in diameter. 

The inferior basin, also measured transversely at the linea ileo- 
pectinea, gives 4.6 inches in diameter. 

The greatest depth of the upper bowl, down to the plane of the 
superior strait, is 2 inches. 

The greatest depth of the excavation, measured as a chord line 
from the top to the bottom of the sacrum and coccyx, is 5 inches. 

The figures represent a transverse section of the pelvis, by which 
it is cut down through the planes of the ischia. They serve to exhi- 
bit the form of the interior of the pelvis, seen from before backwards, 
and from behind forwards : f is the fourth lumbar vertebra and the 
intervertebral ligament; c, c, the crista of the ossa ilia; e, the aceta- 



24 



THE PELVIS EXCAVATION. 




bulura ; 6, 7, the dorsum of the right ilium ; 2, 6, the dorsum of the 
left ilium; &, the point of the coccyx; d d, the tuberosities of the two 

ischia; a, h, the sa- 
cro-sciatic foramina; 
g, the lesser sacro^ 
sciatic ligament; 3, 
4, the greater sacro- 
sciatic ligaments; 5, 
the coccyx. The 
bony sides of the 
excavation are seen 
to be planes — the 
planes of the ischia, 
which approach, or 
are so inclined to- 
wards each other in 
descending as to 
make the transverse diameter of the inferior strait smaller than that of 
the superior strait. 

The third figure exhibits* the arch of the pubis, and consists of 

the anterior half or 
anterior segment of 
the pelvis. 

The depth in the 
middle, or at the 
sides, is 3.5 inches, 
and in the front of 
the bowl, just be- 
hind the symphysis 
pubis, only one inch. 
The shallowness 
of the excavation in 
front, is owing to the 
arch of the os pubis, 
w r hich is the semicircular arch in front, 10 in the engraving, in which 
it is seen that the crown of the arch approaches the top of the pubal 
bone 9, from which it is distant only one inch. This figure shows 
the form of the arch as seen from behind — the pelvis having been 
sawed through in a transverse direction for the purpose of showing 
the arch, e is the acetabulum, c c crista? of the ilium. 

This extreme shallowness in front, gives good reason to speak of 




THE PELVIS STRAITS. 



25 



Fig. 4. 



the pubis as a bar-bone. It is a bar against the escape of the child, 
which cannot be born without going underneath that bar-bone. 

I refer the reader again to the figure of the female pelvis at page 
22, by inspecting which, he may readily make out the upper basin of 
the pelvis as distinguished from the lower basin: also the narrows 
or superior strait, and the arch of the pubis; while at the bottom of 
the lower pelvis he will see what is called the outlet or inferior strait, 
or perineal strait. 

The figure here annexed exhibits the form of the superior strait as 
it appears when seen by looking at it in a direction from above 
downwards. It is shaped like the heart on a playing card. The 
lines a b, c g, e f, are 
the diameters of the 
strait. 

I also insert a cut 
which represents the 
form of the lower or 
perineal strait, seen 
from below. Its form, 
though symmetrical 
like that of the supe- 
rior strait, seems less 
regular in its outline. 
It fulfils the design, 
however, to w 7 hich it 

w T as appropriated, as perfectly as the more elegant form of its fel- 
low ; and it will be found, upon prosecuting the study of the organ? 
that this particular aper- 
ture is admirably adapted, Flg- 5> 
not only to render more 
secure the fruit of the 
womb during a pregnancy, 
but to give passage to it 
in labor. The student 
ought always, in studying 
this part of his subject, 
to have at hand a good 
specimen of the female 
pelvis; but he should take 
notice, that, in the recent 
or living subject, these bony surfaces are invested with divers tis- 





26 THE PELVIS LIGAMENTS RELATION TO PRESENTATION. 

sues, and sustain various organs -whose bulk and consistency give to 
the bony cavity an appearance and capabilities exceedingly different 
from those of the dried specimen. The lines that cross it in different 
directions, a b, c d, ef, ef, represent its diameters. 

The two small bones seen on the front of the pelvis, and which 
are respectively called the right and the left os pubis, are firmly and 
immovably united together by a fibro-cartilaginous ligament; and the 
triangular bone situated behind, and which is, in fact, a collection of 
consolidated vertebrae, is held in the strongest union to the side pieces 
or hip-bones, by means of a fibrous substance, called the auricular 
ligament, while the union is rendered vastly more solid and inde- 
structible by means of a quantity of ligament upon the exterior of 
the sacrum and hip-bones, as well as by other fibrous bands, called 
sacro-sciatic ligaments. All these ligaments are most economically 
adjusted, in order to avoid any encroachment upon the space required 
for the transmission of the child in parturition, to which end they are 
distributed either upon the external surface, or they are adjusted be- 
twixt articular surfaces, so as in no wise to diminish the capacity of 
the straits or the excavation. Meanwhile, the whole structure ac- 
quires, by means of them, the requisite strength and solidity; a 
strength that is, perhaps, greater than if they had consisted of a 
single bone. 

The obstetric pelvis has relation to the transmission of the child 
through the straits and excavation. A child at term is eighteen or 
twenty inches in length. It is obvious, then, that it must, while 
within the womb, be strongly flexed, the head being bent forwards 
upon the breast, the thighs flexed upon the belly, and the legs flexed 
upon the thighs, while the arms are pinioned against the sides in front 
of the thorax, in flexion. 

This state of universal flexion gives to the foetus the shape of an 
olive, Fig. 6. The olive-shaped mass is about twelve inches in its 
longitudinal, and four inches in its conjugate diameter; whence it is 
evident that, in a labor, one pole of the olive ought to present itself 
to the straits, which are large enough to give passage to a body only 
four inches in diameter. 

Can the student suppose that it is a matter of serious import to the 
woman, whether the cephalic or the pelvic pole be the presenting 
part? Not so, however, as to the foetus — to whom it is of immense 
importance that the cranial pole should be the first to descend. The 
cut exhibits the olive-Hke form in which the foetus lies packed 
while in the womb, and it ought to show that it is nearly indifferent 



THE PELVIS — SACRUM. 



27 




as to the mothers interests whether one or the other extremity of the 
foetus approaches the os uteri. 

In order to obtain very accu- Fi s- 6 - 

rate notions of the pelvis, all the 
portions of which it consists 
ought to be separated and stu- 
died, each in succession; to 
which end, I shall now proceed 
to enumerate them. They are 
eight pieces, whose names are 
as follows: — the sacrum; the 
coccyx; the right ilium; the 
left ilium ; the right ischium ; 
the left ischium ; the right pubis, 
and the left pubis. Thus, the 
student becomes master of the 
names of the eight pieces of 
which a pelvis is composed. 

As to its shape, the sacrum is a triangular pyramid. The inner 
face is larger than either of the two outer faces. It is concave, 
whereas their faces are convex. Hence, the pyramid is bent towards 
the excavation, and its concave face is what is called in midwifery 
the hollow of the sacrum. 

The sacrum has the following parts that are worthy of notice: — 1. 
The base. 2. The apex. 3 and 4. The two edges. 5 and 6. The 
two auricular facettes. 7. The sacral foramina. 8. The concavity 
or hollow. 

The base is of a triangular shape. 

At the base is to be seen the articular surface by which the bone, 
covered with its intervertebral cartilage, was united to the last lumbar 
vertebra. The anterior edge of that articular surface is the most 
salient point of the promontory of the sacrum; and there, also, is 
found the sacro-vertebral angle, so called, because the lumbar spine 
and the sacrum are joined together so as to make an obtuse angle at 
the place of junction. The words promontory, projection, and sacro- 
vertebral angle, are used as synonymous terms. 

The sacrum is fully four inches wide, measured from wing to wing, 
at its base. In descending, it becomes narrower down to its apex 
or point, upon which is an oblong or oval articular facette, by which 
it is united in the living subject to the os coccygis. 



28 



THE PELVIS — SACRUM. 



Fig. 7. 



Behind the edges of the sacrum, where the bone is broad, is seen 
upon either wing a smooth surface shaped like the human ear, whence 
it is called the auricular surface. There is a similar one on each hip 
bone or coxal bone, for the purpose of articulation. A strong fibro- 
cartilage, called from its form, the auricular cartilage, passes from 
the sacral to the coxal surface: it is about a sixteenth of an inch in 
thickness. It has no synovial cavity; and is so very strong that a 
considerable effort is required to separate the bones, even when held 
together by this ligament only. There are samples of labors in 
which this powerful bond of union has been broken by the violent 
efforts of the patient in thrusting the child through a pelvis too small 
for its passage. The adjoining figure of the sacrum represents its form 

very correctly, as seen in looking upon 
its front or hollow surface. It is about 
four inches long, and at the widest 
part, the breadth equals the length. 
This surface is the posterior wall of 
the excavation of the pelvis. There 
is observed a double row of holes or 
foramina for the transmission of nerves 
that come off from the brush-like 
extremity of the spinal cord. Four 
holes are to be counted in each row; 
occasionally a specimen is seen to 
contain five in each row. 

By filling these holes with putty, 
and pouring water upon the surface 
while holding the bone in a horizon- 
tal position, the cup will be found deep enough to hold an ounce of 
water, sometimes more, sometimes less, according as the hollow is 
deeper or shallower. 

Let not the Student disregard these foramina. He should observe 
the shallow grooves in the bone that lead to the holes, and reflect 
upon the comparative security thus given to their nervous cords, 
which, in most instances of labor, are by this means protected from 
injurious pressure by the head of the child or by any instruments used 
in midwifery. 

Pressure upon a nerve gives pain; violent pressure gives rise to 
intolerable agony, or it inflames or kills the nerve: let him, then, 
ponder on the possible consequences of pressure and contusion for 
the limbs that are supplied with nerve-force by means of these sacral 
bundles. 




THE PELVIS SACRAL FORAMINA. 29 

While speaking of these internal sacral holes for the transmission 
of nerves, I may seize the occasion to insist that the compression of a 
nerve produces pain, and the pain is generally intense in the propor- 
tion of the violence done to the nerve — short of wholly destroying it. 

A child's head can scarcely get through the pelvis without com- 
pressing, more or less, some one of the nerves in range either on the 
right or left side of the sacrum. When the head rests upon one of 
these cords, the muscle or set of muscles innervated by it are thrown 
into spasm or cramp ; whence it is an ordinary occurrence to hear 
women. in labor complain of cramp in the thigh, the leg, &c, which 
ceases when the pressure is relaxed, and which returns again with the 
effort, until the head has passed down lower than the nerve — after 
which the cramp is nowhere felt. 

I think one of the most fearful sights of human agony that my eyes 
have ever witnessed, was that of a lady in North Sixth Street, Mrs. 

Th. S y, who, being in labor of her first child, and making rapid 

progress towards a delivery, began suddenly to scream, with the 
greatest violence, after uttering the words, "Oh, the cramp! the 
cramp! the cramp!" She was indescribably agitated, her counte- 
nance assumed the wildest expression, and all the persons in her 
chamber became much alarmed on account of the very extreme de- 
gree of anguish, or rather agony, which was depicted in her counte- 
nance and expressed by her shrieks. I had, for many years, been 
accustomed to the cries of puerperal women, to which I had become 
very indifferent, but this case deserved to be called terrible. The 
cramp affected the muscles of her right leg. I explained to her that 
the cramp was caused by the pressure of the child's head upon one 
of the right sacral nerves, and, though the appearance of the case was 
appalling, I exhorted her to bear down, hoping a few vigorous efforts 
would push the head lower than the point of pressure, and relieve her 
from the misery. I was disappointed; the cries ceased with the 
relaxation of the throe, only to return with every renewal of the con- 
traction. So intense was her distress, that she began soon to show 
signs of exhaustion of nerve-force, and I have now no doubt that she 
was in imminent danger of d^eath from the excess of pain. The 
labor was arrested, as to its progress, with every renewal of the 
labor pains ; and it appeared that her whole life-force and perception 
w r ere occupied with this sole agony. I was three-fourths of a mile from 
home ; and while her husband was gone for my forceps, for which I 
immediately sent him, she renewed her cries about every four minutes. 
I think she would have died in half an hour. Upon receiving the 



30 THE PELVIS SACRAL FORAMINA. 

instrument, I speedily applied it and drew the head below the com- 
pressing point, and she bore the extraction without murmur, for the 
nerve was set at liberty as soon as I had drawn the head below it. 
For more than a fortnight after the labor there was a partial paralysis 
of the limb, following the pinch the nerve had suffered betwixt the 
foetal head and the bony pelvis. It did not wholly disappear for 
many days. Two years later, I encountered a similar scene in the 
same apartment. She seemed to dread nothing in the approaching 
labor but the "cramp!" and engaged me to be prepared with my 
forceps, which I unfortunately declined to do. When the head de- 
scended into the pelvis, she was seized with precisely the same kind 
and degree of pain; the forceps were brought to me from the same 
distance, and she was again as speedily relieved. In this labor, as 
in the former, a partial paralysis and numbness of the leg followed 
the parturition, and did not disappear until the month was out. 

In a third labor, during which I was confined to my house by sick- 
ness, she came under the care of my able colleague, Dr. R. M. Hus- 
ton, well known for his skill as an obstetrician. The same scene was 
renewed in this third case, and the Doctor felt obliged to relieve her by 
extracting the head with the forceps. I have attended her in a fourth 
labor in the year 1846, in which the position of the child was such as 
to avoid the pressure, and she gave birth to her infant without cramp, 
or any uncommon pain. 

I was in attendance upon a lady living in Turner's Lane, two and 
a half miles from my house. The labor had proceeded very towardly 
until the head got well down into the pelvis. I was in a lower par- 
lor conversing with her husband when we were both startled by the 
sudden, sharp screams of the patient from her chamber in the second 
story. We both hastened to the apartment, where I recognized a 
scene in all respects like those witnessed in the accouchement of 

Mrs. S y. After vainly exhorting my patient to bear down and 

push the child lower than the nerve, I engaged Mr. to wake his 

servant, for it was night, and send him on the fastest horse to the city 
for my forceps. Her agony was indescribable during the whole pe- 
riod of his absence. He had a ride of five miles — out and in. I got 
the instrument, and the child was delivered within two or three min- 
utes after it was placed in my hands. No evil consequences fol- 
lowed the pressure in this case. She had had several children, but 
in none of the labors had the nerve got so severe a pinch. 

Here, then, are four cases of forceps operations rendered indispensa- 
ble by pressure on the sacral nerves. I have seen no accounts of 



THE PELVIS COCCYX. 31 

similar instances in the books. I have met with many hundred 
labors in which cramp was more or less violent; but these cases, 
above mentioned, were really frightful, and I have no doubt that both 
the distress and the danger were sufficient warrants for the instru- 
mental assistance. 

The movableness of the coccyx upon the sacrum is much relied 
upon as a means of amplifying the antero-posterior diameter of the 
lower strait of the pelvis. I do not think that the point of the coccyx 
usually recedes much during the transit of the foetal head in parturition. 

I here present a figure that represents the terminal or caudal ex- 
tremity of the spinal column of the natural 
size. It is called the os coccygis or cuckoo 
bone, in vulgar language the crupper bone. 
It consists of three pieces, altogether about an 
inch and a half long, that are separable in the 
young, but become anchylosed into one solid 
piece as advance is made in years. Two 
styloid processes ascend from the posterior 
lateral surfaces to rest upon the back part of 
the apex of the sacrum and prevent the point 
of the coccyx from being driven too far back- 
wards by the displacing pressure of the foetus 

in labor. The cornua, however, are not strong enough always to re- 
sist, and they occasionally break off with a loud sound. The sound 
may be heard at the distance of many feet from the woman in travail. 
In general, no very great inconvenience is produced by this fracture ; 
although there are met with a few instances in which a long-continued 
pain follows the accident. 

In young women, the articulation of the coccyx and sacrum is a 
movable one; anchylosis takes place in those who be°in to grow 
old, advancing beyond the youthful season of bloom and beauty. 
Hence, it is better that a woman should have her first children before 
this bony anchylosis takes place, inasmuch as when the sacrum and 
coccyx have become immovably joined together, the point of the little 
bone may arrest or distressingly retard the acts of child-birth. 

Most writers attribute to the coccyx a power to recede very con- 
siderably. My own observation has led me to regard this recession 
as less than it is generally admitted to be, and inspection confirms 
this doubt. The point cannot go very far backwards but at the ex- 
pense of a fracture of the cornua and of the lesser sacro-sciatic liga- 
ments which tie it firmly in a certain proximity to the tuberosities of 
the ischia. 




32 



THE PELVIS — SACROILIAC JUNCTION. 



Fk. 9. 



The manner in which the sacrum is joined to the coxalia or hips is 
worthy of attention. The two auricular facettes converge both down- 
wards and backwards, and are furnished with opposite bulbs and de- 
pressions, fitting into each other with the interposed fibro-cartilage 
before described. This double convergence of the surfaces has the 
effect of a dovetailing to prevent the sacrum from slipping down be- 
twixt the hips, when weighed down by the weight of the over-bur- 
dened body, or of being driven backwards by the resistance of the 
child in labor. The great groove or channel on the back part of the 
pelvis is almost filled up by means of ligament, so that there can be 
no stronger joint in the whole skeleton than the sacro-iliac joint. 
The cut is designed to show the sacro-vertebral angle, which is the 
point touched by the finger of the hand repre- 
sented in the figure, and the shape of the sacral 
curve; it represents an antero-posterior section 
of the bone through its middle. In it the base 
of the sacrum appears to project or advance over 
the excavation like a promontory. A chord line 
from the promontory to the point of the coccyx 
gives a sine of an inch, which is the greatest 
depth of the hollow. 

A badly shaped sacrum causes great diffi- 
culty in labor. Whether the curve be too shal- 
low or too deep, it is unfavorable ; the figure 
represents a desirable one. 
Having thus given an account of the os sacrum and os coccy- 

gis, our attention ne- 
cessarily turns to the 
hip-bones, called cox- 
al-bones, nameless- 
bones, or ossa inno- 
minata, which make 
up the sides and front 
part of the pelvis. 
Annexed is a cut that 
represents the right os 
innominatum or hip 
bone. The very name 
it bears affords suffi- 
cient evidence of the 
difficulty of describing 




Fig. 10. 




THE PELVIS — OS INNOMINATUM. 



33 



it in words ; I therefore request the reader to refer to the drawing, 
which affords a very correct notion of the form and arrangement of the 
several parts of which it consists. It is divided into three parts or 
pieces, that are named respectively the os pubis, os ischium, and os 
ilium. The pubis is on the left of the figure, the ischium at the lower 
part, and the ilium constitutes all the broad portion at the right and 
superior portion of the cut. 

If an os innominatum be taken from a subject under twelve or four- 
teen years of age, and macerated or boiled in water, it readily sepa- 
rates into three pieces; and the separation takes place because the 
pieces, in an under age, are not consolidated, or become one firm bone. 
The separation occurs in the acetabular region, where the several 
pieces are as yet not firmly united by ossific fusion ; a union that 
cannot become completed until the body has acquired a degree of 
development fitted to enable it to undergo the fatigue of gestation, 
which rarely occurs until the fifteenth year. A bone, taken from the 
os innominatum of a subject about twelve years old, serves to show 
the student the propriety of preserving for the adult skeleton the 
names of the three juvenile pieces ; for he will learn thereupon that 
it is very convenient to refer to them, in many cases, when we desire 
to direct the attention accurately to a certain point of the pelvis, of 
which we can then speak, as its ischial, pubic or iliac, portion. 

Fig. 11 is a representation of the appearances observable upon 
the exterior surface of the 



right os innominatum — 1 is 
the dorsum of the ilium; 2 
is the acetabulum; 3, the 
venter, costa, or fossa ; 4, 
the anterior superior spinous 
process of the ilium; 5, the 
anterior inferior spinous pro- 
cess; 14, the tuberosity; 15, 
the ramus ischii ; 18, the 
descending ramus of the 
pubis ; 19, the symphysis 
pubis; while 20 is the thy- 
roid foramen, or obturator 
foramen. 

The anterior fifth of the 
acetabulum belongs to the 



Fig. 11. 




34 THE PELVIS OS INNOMINATUM. 

pubis, the lower two-fifths to the ischium, and the upper and outer 
two-fifths to the os ilium. 

Upon the right inferior portion of the shaded drawing, Fig. 10, is 
seen a rough surface (7), shaped somewhat like a human ear — whence 
it is called the auricular surface. This rough disc is covered, in the 
recent subject, with a fibro-cartilage that seems to grow out of the 
bone, and is shaped exactly like the auricular surface; it is about one- 
sixteenth of an inch thick, as mentioned in describing the sacral auri- 
cular facette, into which it is inserted as strongly as it is into that of 
the innominatum. 

On the left extremity of the figure is another articular facette (17), 
that of the symphysis pubis. The inter-pubic ligament passes from 
this facette to its fellow on the left os pubis. 

The lower part of the picture (14), shows the rough tuberosity of the 
ischium, sciatic bone, or sitting bone, the point upon which the body 
rests when in a sitting posture. 

Just above and behind the tuber ischii is a sharp point, or spinous 
process (13), that is called the spine of the ischium. 

Between the lower end of the auricular facette of the ilium and the 
posterior extremity of the tuberosity of the ischium, is a deep incisura 
or notch (8), called the sacro-sciatic notch, because the incisura lies 
between the sacrum and the ischium. Inasmuch as the ilium also 
forms a part of the margin of this notch, it would be a better nomen- 
clature to call it the ilio-sacro-sciatic notch; which would express an 
anatomical truth fully. 

This notch is divided into the greater and lesser, and is converted, 
by means of the sacro-sciatic ligament, in the recent subject, into 
two large foramina or openings, through which pass certain nerves, 
vessels, and tendons of muscles. 

It would be improper, in this cursory examination of the os inno- 
minatum, to omit a reference to the smooth, or plane surface of the 
ischium, which is technically called the plane of the ischium. It 
is all that part of the inner surface of the bone that is bounded by 
the pubis and ilium above, by the sacro-sciatic notch behind, by 
the inner lip of the tuberosity below, and the posterior part of the 
obturator foramen in front. It is particularly denominated the 
inclined plane of the ischium, because the plane, in descending, 
approaches the plane of its fellow on the opposite side of the exca- 
vation. 

The Pubis. — The pubis is the smallest bone of the innominatum ; 



THE PELVIS OS INNOMINATUM. 



35 



it is the shear-hone — the bar-bone — the cross-bone — called, in Latin, 
os pubis, and also os pectinis; from pecten, a comb. 

As the pudenda is clothed with hair, the term pecten has been 
applied to that region, and the bone of the pubis has been called the 
os pectinis. Juvenal speaks of the pecten in Sat. vi. 370. 

Inguina traduntur medicis jam pectine nigro. 

The pubis is divided into the body, the symphysis, and the ramus. 

The body of the bone occupies about one-fifth of the structure com- 
posing the acetabulum, from whence it extends, the right one towards 
the left, forwards and downwards, and the left one, to the right, for- 
wards and downwards, until the two symmetrical bones meet in the 
anterior median line of the pelvis at a point called the symphysis 
pubis, where they are held in strong union by the inter-pubic liga- 
ment. 

The two symphyseal extremities of the bones are rough, as giving 
origin to the fibro-cartilage which unites them. 

From each symphyseal extremity there descends a thin flattish 
branch or process, called the ramus of the pubis, which is fused with 
the ascending ramus of the ischium, both of the left and the right side. 
The divaricating edges of these rami give the form of an arch, which 
is called the arch of the pubis. 

The body of the bone, as has been said, extends itself towards the 
symphyseal extremity — and that extremity sends down its ramus — 
so that there is left between the inferior edge of the body and the 
interior edges of the 

ramus of the pubis Flg * 12, 

and ischium, and 
the anterior edge of 
the plane of the 
ischium, a large va- 
cuity, which is the 
thyroid foramen be- 
fore mentioned. 

The pubis is often 
called, in English, 
the shear-bone, and 
the bar-bone. The 
figure gives an idea 

of the form of the pubis — as to its body, its symphysis, and its ramus 
— seen from behind looking forwards, or anteriorly. 




36 



THE PELVIS LIGAMENTS. 



Fig. 13. 



Let me again advise the student not to despise the strong English 

word, bar-bone, since its meaning is 
pregnant. This bone is really the bar 
on which turns the foetal head in its act 
of extension ; and the word bar-bone is, 
therefore, a very expressive one. 

The diagram (Fig. 12) may serve to 
show a symphysis pubis and sacrum cut 
through, and exhibiting half the carti- 
lage by which the pubis was joined to 
its fellow. This symphysis is half an 
inch thick from front to rear, and an 
inch and a half high from top to bot- 
tom. It is the bar which impedes the 
progress of the head in front, and which must go under the bar, to 
get into the world. In doing so, the head revolves beneath the bar- 
bone, as shown in the figure of the head marked in strong outline, 
and likewise in the successive positions it assumes (as indicated by 
the fine outlines), in revolving beneath the bar-bone. When the 
obstetrician takes the head by force of instruments from behind the 
bar to bring it into the world, he must do so by drawing it underneath 
the bar, as shown in the three figures. In the figure, Extension of 
the head is already begun, for the vertex has come a little way out of 
the strait. 




Symphyseal Ligaments. — The two symphyseal ends of the pubes 
are, as I said, united by a fibro-cartilage, passing interchangeably 
from one bone to the other. The lower edge of this ligament is 
called the triangular ligament. It serves both to strengthen the union 
and to depress the crown of the pubic arch, which arch is thus made 
rounder and lower, and softer. If the head were pressed immedi- 
ately against the bony structure, that structure, from its inelastic hard- 
ness, would contuse the soft parts of the woman or those of the child ; 
whereas the ligament is of the nature of a soft and elastic cushion. 

In dividing the symphysis, there is sometimes, not always, found 
in the centre of it a very small synovial sac. 

The ligaments of the pelvis are of very great importance. The 
firmness of the pelvis as an organ for transmitting the weight of the 
trunk to the lower extremities, and propagating their motion inversely 
to the trunk and limbs, is dependent upon the ligaments. I shall pre- 
sent the reader here with a view of them taken from a distinguished 



THE PELVIS — LIGAMENTS. 



37 



author, who, I hope, will not object to my exhibiting to the American 
student a copy of his beautiful drawing. I refer to Dr. Frederick 
Arnold, from whose Tabula Anatomicce, Fasciculus IV. Pars II. 
Continens Icones Articulorum et Ligamentorum, fol. Stuttgard, 1843, 
I have taken Fig. 13. In this figure the letter g is the sacrum ; s s s 
the posterior sacral foramina; h the os coccygis, j the right os innomi- 
natum, of which a portion has been removed, o the posterior superior 
spinous process of the ilium, b the greater sciatic notch, 10 the 
superior ilio-lumbar ligament; 11 inferior ilia-lumbar ligament; 12 
superior sacro-iliac ligament; 13 the posterior superficial sacro-iliac 
ligament; 15 sacro-sciatic ligament; 16 the sacro-spinous ligament; 
17 the sacro-tuberous ligament. 

Fig. 14. 




From a mere inspection of Dr. Arnold's figures it is evident that 
the chief ligamentous strength of the sacro-iliac junction depends, 
1st, upon the powerful ligaments on the back part of the pelvis, out- 
side of the excavation ; and 2d, on the firm cohesion of the symphysis 
pubis by means of the strong inter-pubic ligament. The auricular or 
sacro-iliac cartilage is not represented, and yet it is so strong that I 
have been much foiled in endeavoring, before my class, to tear open 
the sacro-iliac joint by pulling asunder the ossa pubis after I had per- 
formed the section of the pubic ligaments: the origin or insertion of 
the auricular cartilage must be torn out from the bone before it will 



38 THE PELVIS RELAXATION OF JOINTS. 

yield, for the fibres will not break. They can only be torn out by 
the roots. 

Opening of the Joints. — Many people among the mass of society 
suppose that in every labor, the joints become relaxed, in order to let 
the child pass through the bones ; and a good many ladies take a 
spoonful of oil of olives or palma christi, with a view to promote this 
desirable relaxation as they esteem it to be. I have known a young 
thing take the trouble, nightly, to anoint the mons veneris for a long 
period, with lily ointment, to soften the joint. 

It is understood, however, by the anatomist, that these joints do not 
become open and relaxed as a normal effect of gestation, of labor or 
of endermic or therapeutical measur&s, resorted to for that end. Yet 
they do, in some persons, relax, to their great injury or inconvenience. 

As to the symphysis pubis, I have on many occasions found it to be 
quite loosened, and admitting of motion. One of my patients, whom 
I have succored in many of her confinements, has greatly suffered 
from the relaxation of the symphysis pubis during the several last 
weeks of her pregnancies. The articulation becomes so loose as to 
make a very considerable cracking sound, when she would turn in 
bed, or walk; and she has been good enough, in order that I might 
verify the fact, to allow me to cause the motion by pressing with my 
hands on the opposite spinous processes of the iliac bones, by which 
means 1 could cause the two opposite pubes to approach or separate 
from each other, or ride up and down, passing each other in the di- 
rection of the length of the symphysis. 

When the patient in such a state of the interpubal ligament stands 
on the right foot, the right pubis rises upwards, while the left descends, 
and vice versa — so that the act of walking is not only attended with 
pain, but with tottering and uncertainty. 

The lady in question gives birth to children weighing ten and 
twelve pounds, but she has commonly recovered from the relaxation 
within about forty days after the birth of the child, and her pubic joint 
remains perfectly strong and efficient, until in an advanced stage of 
the next gestation, the pressure and the infiltration come to loosen 
and dispart the bones again. 

This lady has been fourteen times pregnant, and has given birth to 
twelve children at term. The joint did not give way until the sixth 
accouchement, which occurred Oct. 20th, 1833. The child weighed 
upwards of twelve pounds. The motion of the symphysis was very 
obvious, and very painful. She recovered from it, however, and did 



THE PELVIS PLANES. 39 

not feel it again until near the close of a pregnancy, which was con- 
cluded on the 12th December, 1835, by the birth of a son. In about 
a month the articulation was again firm as ever. A daughter was 
born October 30th, 1837, which reproduced the relaxation. She soon 
got over this, and in the next pregnancy and confinement felt nothing 
of it. This labor was on the 2d of September, 1843. When the child 
was three months old, the relaxation took place, and was long trouble- 
some. She was again pregnant in 1845, but had no return of the incon- 
venience in the gestation or lying-in, which occurred January 20th, 
1846. The joint gave way again soon after her last accouchement, 
Aug. 17, 1848 ; she discovered it on the 20th day of the month, and 
it is so movable, that a cracking sound is produced by turning in bed. 
Having now described with sufficient detail the several constituent 
bones of the pelvis, it is proper to take a view of the whole of that 
structure, which deserves to be regarded somewhat in the light of a 
great and important organ of parturition. 1 do not speak of it as of 
one of the items belonging to the domain of a special anatomy. 

The Whole Pelvis. — The female pelvis is divided into two por- 
tions, two cavities, two basins, or two pelves, one of which is the 
upper, and the other the lower; the greater, the lesser; the superior, 
the inferior ; the pelvis, the true pelvis or excavation, or cavity. 

The division betwixt the two portions is to be found at the linea 
ilio-pectinea, for the whole pelvic cavity is in a sense, worthy to be 
called, as it often indeed is called, a canal, a bony canal, the pelvic 
canal, in which is a narrows or straits, as the Dardanelles is a strait 
betwixt the Black and Mediterranean seas, parva componere magnis. 

The strait betwixt the upper and lower pelvis is called the superior 
strait; and it is a strait, because above it is the great, the larger basin, 
and below it is the smaller or lesser basin, w T hich, however, is a part 
where the pelvis is more spacious than it is at the strait itself. 

Plane of the Superior Strait. — The plane of the strait is an 
imaginary superficies, the anterior margin of which is at the sym- 
physis pubis, its posterior margin at the promontory, while the rest 
of its margin touches the inner lips of the linea ilio-pectinea. 

When the woman stands erect, or lies at length on the back, the 
plane of this strait dips at an angle of 50° to the axis of her body. 

Inclination of the Plane. — It must clearly appear that the plane 
of the superior strait dips at a variable angle in various positions of 
the trunk of the body; for if the subject be standing, it dips as above 
at 50°, but if the trunk be inclined forwards, the dip will be lessened ; 



40 



PLANES OF THE PELVIS. 



or if the trunk be inclined far backwards, it may be increased. Now 
this is an important item of obstetric knowledge, since upon it is 
founded our advice as to the decubitus of the patient, whom we may 
direct to extend her trunk or to flex it more or less, as we may desire 
to bring the plane of the superior strait into a position that may favor 
both the entrance of the presenting part into the strait, and its pas- 
sage through it. 

The figure is designed to show that the plane of the strait may give 

different angles with the spine, 
s * • according as the spine is brought 

more forward, or carried farther 
\ ! backwards over the opening. 

Thus e e e is a circle of which 
the diameter b f represents the 
inclination of the plane of the 
upper strait, equal to an angle 
of 135° f a, which is the ordi- 
nary altitude of the spinal co- 
lumn or axis of the trunk. If the 
patient lying upon her back 
should have her shoulders raised, 
so as to carry the spine forward 
to c, equal to 22.30°, the angle 
would be reduced to 112.30°. 
But if the shoulders should be 
still more elevated to d, the axis 
of the trunk would be at right 
angles to the plane of the strait 

bf- 

The same effect as to the incli- 
nation of the plane of the strait is 
produced in the patient, lying on 
her side, whenever she bends her head and trunk forwards; and, 
indeed, in labors, we see women constantly prompted by an instinctive 
sense of the utility of it, bending the trunk quite over the abdominal 
strait, to which, moreover, the old nurses and experienced crones 
urgently exhort them. A child's head, that in one inclination of the 
plane should be driven against the symphysis pubis, would with a 
lesser inclination of it plunge at once to the bottom of the pelvis. 

Justus Heinrich Wigand, the lamented author of the celebrated 
volume entitled Die Geburt des Menschen, was deeply impressed with 
the importance of a careful attention to the inclination of the plane, 




PLANES OF THE PELVIS. 



41 



Fig. 16. 



in Labors. He often made use of his knowledge of it as a foundation 
of his prognosis. I have copied these outline figures from the second 
edition of his work, by Froriep. They represent the female torso 
in profile. Each figure has marked upon it six lines, of which the 
two horizontal ones extend parallel to each other, from the promontory 
of the sacrum and the symphysis pubis respectively. 

In a well-formed pregnant female, the profile will resemble the 
outline figure, provided the child be not very 
large, nor the liquor of the amnios excessive in 
quantity. As in Fig. 16, the back bone will 
not be excessively curved. A line drawn hori- 
zontally forwards from the top of the sacrum 
will pass out at the navel, and equal angles will 
be formed by a line drawn from the top of the 
sacrum to the symphysis pubis, which indicates 
the inclination of the superior strait, and one 
drawn from the same point to the scrobiculus 
cordis. A line from the scrobiculus cordis to 
the symphysis pubis, will be perpendicular to 
the one first mentioned. 

Inspection of such a figure might well serve to 
establish a favorable prognosis ; since, cseteris 
paribus, any untoward circumstances would be 
very little to be expected with so perfect a form, 
proportion, and arrangement of parts. 

This, Fig. 17, is a copy of Wigand's figure 
3d, in which he proposed to represent the pro- 
file of a pregnant woman of apparently perfect 
form, but the inclination of whose superior 
strait is excessive, as may be seen by ob- 
serving the line drawn from the top of the 
sacrum to the top of the symphysis pubis. 
In such a patient the plane of the strait looks 
almost backwards, and the indication of Con- 
duct would be to cause her to bend her body 
strongly forwards, flexing her thighs very 
much upon the pelvis. Such a direction alone 
might suffice to correct the excessive inclina- 
tion of the plane, whereas, if she should lie 
on the back with the shoulders low, and the 
limbs extended, the presenting part could 




Fig. 17. 




42 



PLANES OF TEE PELVIS. 



v fail to be driven upon the top of the ossa pubis. In this 
figure the back is mack more curved than in the former one. The 
horizontal line, from the base of the sacrum to the symphysis, rises far 
e the navel, and the upper triangle or that of the scrobicle is much 
smaller than that of the pubis. The line falling from the scrobicle to 
the pubis retires, whereas in the former figure it is perpendicular. In 
this figure the perpendicular line from the base of the sacrum is fai 
in advance of the upper dorsal vertebrae. 

The contemplation of these ingenious profiles of the admirable Ger- 
man cannot fail to increase the tact and knowledge of the student, 
to whom the study of them is warmly recommended. 

Here is Wigand's Fig. 4, in which is the profile of a woman with a 

pelvis so deformed as to imply a 
necessity for the operation of per- 
foration, on account of its vitiated 
conjugate diameter. The angle 
formed by the back part of the 
sacrum and spinal column is 
much too small. The bend is 
quite different from the gentle 
curve -::: in the first profile. 






F:s. IS. 




The scrobicle proj ects ve y much 

over the symphysis pubis, as by 

the line uniting them may be 

seen. T::e horizontal line from 

the base of the sacrum comes 

out just above the navel. The 

line from the scrobicle to the 

base of the sacrum, and that from 

the sacrum to the pubis are not 

equal — as in the first and more perfect figure. The chord line from 

the promontory to the coccyx retires, and the whole of it is in rear of 

the upper part of the spinal column. 

"Wigand's 5th figure represents a pregnant woman, the conjugate 
diameter of whose superior strait does not exceed one inch or one 
inch and a half; and which, according to most of the German ac- 
coucheurs, indicates a resort to the Caesarian operation. 

The belly is quite pendulous over the pudenda. The plane of 

the strait mak sharp angle with the horizontal line which 

comes out high above the umbilicus. The back is extremely hollow, 

..sequence of the sinking of the sacral promontory down towards 



PLANES OF THE PELVIS. 



43 



Fig. 19. 



the pubis, and the line from the scrobiculus cordis to the ossa pubis 
retreats strongly in a backward direction, leaving the breast to hang 
far dver the pudenda in front. The curve of the sacrum is sharp, and 
the compensating curvature of the upper part of the vertebral column 
is highly characteristic of this 
malformed pelvis, and is an evil 
omen to the unfortunate woman. 
Such are some of Wigand's 
outline figures. I believe that the 
study of them will be very useful 
to the student. It takes many 
years of practice, and a great 
clinical experience and close 
observation like Wigand's, to 
enable one to become possessed 
at a glance, of the peculiarities 
of the case. He, however, was a 
Master in our art, a man who 
devoted his time to its improve- 
ment, and spent the last moments 

of his truly missionary life in laboring to complete the beautiful volume 
from which I have taken his drawings. It is a privilege and an 
honor to evoke such a man from his too early grave, in order that he, 
though dead, may yet speak in this distant land. 




Plane of the Inferior Strait. — The plane of the inferior strait 
is usually regarded as bounded by the inner lips of the two tubero- 
sities of the ischial bones, 

the rami of the ischia and Flg - 20 - 

pubis, the ischio-sacral 
ligaments, and the point 
of the coccyx. In this way 
we speak of the plane of 
the inferior strait as one 
plane only ; whereas, there 
are in fact , two such planes, 
an anterior and a posterior. 

This figure exhibits the 
contour of the outlet. The 
line c d represents the 
transverse diameter. The letters c ea ed show the anterior semi-cir- 




44 



DIAMETERS OF THE PELVIS. 



cumference, while c fbf d show the posterior semi-circumference 
of the outlet. Now from c d to a is an inclined plane, and from c d 
to b is another inclined plane. These planes intersect each otfeer at 
an angle of 140°, and they ought to be distinguished as the anterior 
and as the posterior inclined planes of the perineal strait. 

In midwifery it will be found that as the child descends, in order to 
escape from the womb, it first impinges upon the posterior inclined 
plane, which it depresses first, and then begins to depress the poste- 
rior edge of the anterior inclined plane. When it has succeeded in 
depressing the edges of the two planes, it escapes betwixt them, 
whereupon they resume their place like two valves, whose 'floating 
margins had been first violently separated, and then allowed to close 
again. 



Diameters of the Pelvis. — The diameters of the pelvis are cer- 
tain imaginary lines extending across the pelvic canal in different 
directions, but having reference, in the books, chiefly to the mensura- 
tion of the straits, or narrowest parts of the pelvis. 

For the superior strait there are assigned four diameters, which are, 
1st, the antero-posterior ; 2d, the transverse; 3d, the right and 4th, 
the left oblique diameters. 

In the figure, a b is the antero-posterior diameter, which extends 

from the symphysis 
Fig- 21 - pubis to the promon- 

tory of the sacrum ; e 
f is the transverse, 
while g c and g c trace 
out the places of the 
right and left oblique 
diameters, as they pass 
diagonally from each 
sacro-iliac junction to 
each acetabulum. The 
lines a c and a c mea- 
sure the distance from 
the sacrum to the right 
and left acetabular regions of the pelvis. 

In the inferior strait, vid. Fig. 20, there are reckoned two diame- 
ters. 1st, the antero-posterior, and 2d, the transverse diameter. 
The knowledge of these diameters is of great importance in the scien- 
tific management of labors, on account of their relation and comparison 




DIAMETERS OF THE PELVIS. 45 

to parts of the child, as presenting naturally, or as abnormally pre- 
sented, or placed. 

My measurements of the fetal head were reported to the meeting 
held at Philadelphia for celebrating the one-hundredth anniversary of 
the American Philosophical Society, on the 25th day of May, 1843. 
The mean magnitude of the child's head at term, according to the 
statements made in that paper, is greater than that stated in the books; 
for, of 300 heads measured with the calliper immediately after the 
birth of the child, there were forty heads whose smallest diameter was 
four inches or more than four inches in length; while only one head 
was less than three inches and a half, the usually supposed mean 
length of the transverse diameter. Now, the only interest we take in 
the measurement of the pelvis relates to a proportion between the pel- 
vis and the child that is transmitted through its canal ; but, if the 
child's head is 3.8 inches in its smallest diameter, the dried pelvis 
ought to be more than four inches, in order to allow for it a free 
transit. 

I measured ten pelves, among those in my collection, and the re- 
sults, as to the diameters of the upper and the lower straits, were as 
follows in the table which I subjoin : 





Superior Strait. 




Inferior Strait. 


No. of Pelves. 


Antero-Posterior. 


Transverse. 


Oblique. 


Antero-Posterior. 


Transverse. 


1 


4.2 


6. 


5.3 


4. 


4.3 


2 


4.4 


5.5 


5.5 


3.6 


4.4 


3 


3.9 


4.8 


4.7 


2.7 


4.2 


4 


3.5 


5. 


5. 


2.9 


4.3 


5 


4.2 


5. 


4.8 


3.1 


4.6 


6 


4.3 


4.6 


5.5 


4.1 


4.6 


7 


4.9 


4.7 


4.8 


4.1 


4.1 


8 


4.3 


4.5 


4.3 


4.1 


3.8 


9 


4.4 


4.8 


4.9 


3.6 


4.7 


10 


4.3 


4.8 


4.7 


3.8 


4.2 



The mean in ten pelves is, for the superior strait — for the antero- 
posterior diameter, 4.2 ; for the transverse diameter, 5.1 ; and for the 
oblique diameter, 4.9. For the superior strait — the mean of the antero- 
posterior diameter, is 3.7 ; and for the transverse diameter, 4.3. 

I here present a tabular statement of the dimensions of the pelvis 
taken out of several authors, in order that the American student may 
easily collate opinions, and come to the conclusion, that these dimen- 
sions are not a fixed, but a variable quantity ; and that as one woman 
is taller or shorter than another, or has a larger foot, hand, nose, or 
chin than another, so she may have a pelvis adapted to her own spe- 



46 



AXIS OF PELVIS. 



cial proportions, or a pelvis of four inches to four and a half inches 
in its antero-posterior diameter. 





Sxtpeeioe Strait. 




Inferior Strait. 




Antero-posterior. Oblique. 


Transverse. 


Anlero posterior. 


Transverse. 


Smellie 


4i - 


H 


4i 


—5 


Denmaa 


+4 


+ 5 


+5 


+4 


Burns 


4 5$ 


5* 


5 


4* 


Ashwell 


4 H 


5 


5 


4 


Churchill 










Baudelocque 4 \\ 


5 


4 


4 


Gardien 


4 Ai 


5 


4 


4 


Velpeau 


4 Ah 


5 


4 


4 


Boivin 


4 4£ 


—5 


4 


4 


Chailly 


4 4^ 


5 


4 


4 


Cams 


4 4£ 


5 


3*+** 


4 


Capuron 


4 4^ 


5 


4i 


4 


Dewees 


4-4 4-5 


+ 5 


+4 


—5 



Axis of the Pelvis. — The inclination of the plane of the superior 
strait is so great, that the axis of that plane, if produced, in a down- 
ward direction, would fall upon the sacrum a short distance from the 
apex of the bone. The axis of the superior strait can never, therefore, 
represent the axis of the pelvis. 

The axis of the inferior strait, which is a line falling perpendicularly 
upon the so called plane of the inferior strait, midway from the pubis 
to the coccyx, could not represent the axis of the excavation. The 
antero-posterior diameter of the superior strait and that of the inferior 

strait approach each other at 
g * 22, an inclination which causes 

them to decussate at only 
a short distance in front of 
the pubis, as in the figure, 
in which a b represents the 
plane of the superior strait, 
and o i represents that of the 
inferior strait. If these lines 
should be produced in front, 
they would intersect at the 
distance of an inch or less at 
c. But the lines p c, q c, 
r c, s c, and t c, also repre- 
sent antero-posterior diame- 
ters of the pelvis, or planes of the pelvis, and each one of those planes 
has an axis, which is a line perpendicular to the centre of the said 




CARUS 7 S CURVE. 



47 



plane, so that the axis of the pelvis consists of the axis of the suc- 
cessive planes passed through in descending from the top to the bot- 
tom of the excavation. The line e f, and the line g k respectively 
represent the axis of the superior and that of the inferior strait. 

Carus's Curve. — A far preferable method of describing and under- 
standing the axis of the pelvis, is that proposed by Dr. Carl. Gustav. 
Cams, Prof, of Midwifery in the Medico-Chir. Acad, of Dresden. 
His views are stated in his Lehrbuch der Gyncskologie, etc., Part I 
p. 33, § 44. 

Professor Cams directs that one leg of a pair of compasses should 
be set in the middle of the posterior edge of the symphysis pubis of a 
bisected pelvis, as in the figure, which I have copied from his plate. 
The other leg of the compass 

being opened two and a quar- Fig. 23. 

ter inches, w r hich is half the 
antero-posterior diameter of the 
pelvis, a circle may be drawn 
downwards, commencing at the 
plane of the superior strait, and 
continued through gf, g e, and 
g a to the point of departure. 
This is Carus's circle, the curve 
of which represents, in the ex- 
cavation, the axis of the pelvis. 
This curve of Carus is the bent 

axis of the pelvis, and it is an imaginary curved line, in coincidence 
with which, the centre of the foetal encephalon moves as it passes from 
the upper pelvis through the excavation, the inferior strait, and the 
produced genital aperture, in the act of being born. If the head of 
the child in a labor, should continue to move, after its birth, in the 
same curve it moved in while within the pelvis, the head would come 
back to the point of departure at the centre of the plane of the supe- 
rior strait. 

Such is Carus's curve, or Carus's circle ; which is the bent axis of 
the pelvic canal, an important item of midwifery knowledge ; one with- 
out which a practitioner is incompetent scientifically to deliver a pla- 
centa, and far less to extract a child by turning, or to apply, and 
deliver with, the forceps, or the crotchet. I caution the student not to 
fail in understanding this point very perfectly. If he should make 
himself perfectly familiar with this curve of Carus, I see not how he 




48 



RECENT PELVIS. 



could make an}* mistake as to the appropriate direction of his efforts 
in any act of delivery, whether with the hand alone, or with instru- 
ments. 

The straits, diameters, planes, axes, and curves of the pelvis, are 
related, in an obstetrical view, to a certain form, magnitude, and po- 
sition of the presenting parts of the child, which, in its passage through 
the pelvis, performs certain movements that are spoken of as the 
mechanism of the labor, and which I shall proceed to explain after I 
shall have first spoken of the recent pelvis, and of the child in utero. 

The Recent Pelvis. — The figure, Fig. 24, represents a cross sec- 
tion of the recent pelvis. 
Fig- 24 - In it is seen the sacrum 

covered posteriorly with 
the integuments and 
muscles. The rectum 
lies in front of the ssfr 
cram, and a segment of 
the gut has been re- 
moved in making the 
cross section, because 
the intestine descends 
to the left of the median 
line of the sacral curve. 
In front of the rectum 
is the canal of the va- 
gina, upon the top of 
which is seen the womb 
whose fundus inclines 
forwards while the cervix looks in a direction backwards and d 
wards. The womb rests upon the vagina, which is kept extended by 
means of its connection to the rectum behind, and to the urethra and 
bladder of urine in front, and by no other powers. If the vagina 
should become shorter, the womb would be situated lower down in 
the pelvis; if the vagina should become longer, the womb would rise 
higher. The length of the vagina determines the height of the uterus, 

or its distance from the ostium vag-inse. 

□ 

In front of the vagina and womb, is the bladder of urine, with its 
canal of outlet, the urethra. The bladder lies behind the symphysis 
of the pubis, to which it is attached. The urethra comes out just 
under the bottom of the symphysis. 




RECENT PELVIS. 49 

The bladder is covered, at its summit, with the peritoneal membrane, 
which descends a short distance on its posterior wall or bas-fond, and 
then turning upwards on the anterior face of the womb, passes over its 
top, and thence descends upon its posterior surface, from whence it 
continues downwards upon the back wall of the vagina. It descends 
one-third of the distance from the top to the bottom of the vagina, and 
then mounting upwards again upon the rectum, passes above the plane 
of the superior strait, to give a serous coat to the visceral contents of 
the belly. 

Let the student note the fact that the peritoneum does not descend 
more than half way from the top to the bottom of the front surface of 
this womb — and, therefore, that the front wall of the vagina has no 
relation whatever to the peritoneum ; whereas, the upper third of the 
posterior wall is clothed with a peritoneal coat. An instrument 
thrust through the upper part of the vagina, in a direction forwards, 
would wound the bladder; whereas, one forced through the upper 
part of the vagina, in a direction backwards, would pass into the 
peritoneal sac. This is the weakest part of the vagina, and, therefore, 
most liable to laceration or rupture in labors. It is the part most in 
danger from obstetric instruments. 

The sides of the vagina are related to the spaces included betwixt 
the peritoneal folds of the broad ligaments; and wounds and punc- 
tures, extending sideways or towards the ischial planes, would pass 
into the laminated and very loose cellular tela that exists in the inter- 
stices of the said ligaments. 

The pelvis contains also the levatores ani muscles, which descend 
like the converging rays of a fan, one on each side, and are so inserted 
as to lift the perineum, and consequently, all the movable contents 
of the pelvis, up towards the superior strait. The stronger the leva- 
tors, the deeper is the sulcus betwtet the nates ; and in general, the 
better sustained are the contents of the basin. In the young and 
vigorous the sulcus is deep; in the aged and feeble it descends lower 
and lower, so that, in very old and exhausted persons, the perineum 
becomes actually protuberant or convex. 

In the recent pelvis are numerous blood-vessels and nerves, supply- 
ing the contained organs, besides the large bundles of nerves that 
come out from the sacral foramina and soon leave the cavity, passing 
out through the ischiatic notches to form the great sciatic nerve. 

Here also are contained the ureters — while, overhanging the brim, 
are seen the psoas muscles, which seem to lessen the transverse di- 
ameter of the upper strait. Let the student be particular to note the 
4 



50 



RECENT PELVIS. 



place and appearance of the psoas muscles, as they pass along the 
brim of the pelvis; and let him observe, that, when a woman who has 
recently been delivered, suffers from inflammation of the womb, she 
always experiences pain when she draws up the knees, because the 

overhanging bellies of the 
Flg - 25# psoas muscles, in contract- 

ing, to flex the thighs, press 
very painfully upon the 
globe of the uterus, which 
still juts up above the plane 
of the superior strait, filling 
up the whole of its trans- 
verse diameter. 

The figure may give some 

idea of the relation of parts 

in the recent pelvis, a is 

the aorta, and b the vena 

cava; c the internal iliac 

artery descending into the 

pelvic excavation ; d and f are the external iliac artery and vein ; 

f g the psoas muscles, h the rectum, i the womb, and k the bladder 

of urine. 




MECHANISM OF THE PELVIS. 



51 



CHAPTER II. 

MECHANISM OF THE PELVIS. OF THE MECHANISM OF LABOR, AS IT DE- 
PENDS UPON THE RELATIONS OF THE PELVIS AND THE FCETAL HEAD. 

Before I leave off speaking of the nature of the pelvis, I am to 
treat of what is usually called its mechanism, as dependent upon 
certain forms of the pelvis, and the relations of the child and its posi- 
tion to those forms. 



Fig. 26. 



Flexion, and Obliquity of the Head. — In head presentations, 
the occipito-mental diameter dips its occipital pole, and it generally 
assumes a direction that is oblique as to the plane of the superior 
strait, which it crosses diagonally. 

I say diagonally, for although it be true that a child may descend 
through the plane in a direct position, i. e. with its vertex, or its fore- 
head, to the pubis, such direct positions are rarely to be met with; and 
clinical experience shows that in the immense majority, the head sinks 
below the plane with 
the occipito-frontal dia- 
meter coincident with 
the oblique diameter 
of the upper strait, as 
in figure 26. 

The foetal head usu- 
ally descends through 
the plane of the abdom- 
inal strait in flexion, 
i. e. with the chin to 
the breast, and the 
vertex turned towards 

the left acetabulum, while the bregma, or upper part of the forehead, 
points towards the right sacro-iliac symphysis: vid. Fig. 26. The 
occipito-frontal diameter is probably nearly coincident with the plane 




52 MECHANISM OF THE PELVIS. 

of the strait in the beginning of most labors, whence the occipito- 
mental diameter dips its occipital extremity beneath the plane. 

In proportion as the presenting part descends lower and lower, the 
dip of the occipital pole of the occipito-mental diameter increases. 
It must be so, since the occipitofrontal diameter could not descend 
horizontally into a pelvis too narrow for it. That diameter which, by 
my averages, is 4.10, could not without a dip, or see-saw, sink into 
the lower part of a pelvis whose transverse diameter, low down in 
the excavation, does not considerably exceed four inches. 

The deeper the head plunges into the cavity, the more strongly is 
the chin forced against the breast, or, in equivalent terms, the greater 
the flexion of the head. 

Rotation. — As the pains force the head lower and lower, the vertex 
is driven into strong contact with the plane smooth inner surface of 
the left ischium, which constitutes the left antero-lateral wall of the 
excavation. This plane of the ischium, which is inclined towards its 
opposite fellow, in both a forward and downward direction, repels the 
vertex that is pressed upon it, and the double inclination of the left 
plane serves to compel the vertex to slide downwards, forwards, and 
inwards, towards the pubal arch. It naturally turns towards the arch, 
because there is little to hinder its moving in that direction, save the 
soft parts, which offer a resistance whose force can by no means be 
compared with the resistance of the solid bony wall that repels or 
repercusses it. 

While little resistance is presented in the direction of the arch, or 
outlet, there is likewise very little to oppose the tendency of the face 
and forehead readily to slide into the hollow of the sacrum, that 
seems to gape to receive them. 

Under this view, there can be no doubt that the inclined plane of 
the ischium is the principal cause of the conversion of the oblique into 
the antero-posterior position, which the head acquires, when it reaches 
the lower part of the excavation. The inclined plane, therefore, is 
the chief cause of the rotation of the head. 

Thus, the head turns as it descends. It abandons the oblique atti- 
tude in which it engaged in the strait. Having reached the bottom, 
its occipito-frontal diameter coincides with the antero-posterior dia- 
meter of the pelvis, and the head is, therefore, found to be rotated. 

It was oblique, and in flexion. It has lost its obliquity, but 
still preserves its flexion at the bottom of the excavation; the vertex 
pressing against the posterior margin of the crown of the pubal arch. 



MECHANISM OF THE PELVIS. 



53 



The occipito-frontal diameter has turned one-eighth of a circle, from 
the acetabulum, to the symphysis pubis. 

This is rotation, a term much used in midwifery. 

Extension. — The rotation of the head being now completed, by 
the arrival of the vertex at the symphysis, and of the face in the hol- 
low of the sacrum, the head being still in flexion, the next, or third 
act of mechanism begins to be performed; I mean the extension 
of the head, or the departure of the chin from the breast. 

If the whole perineum could be cut away with a bistoury, I could 
suppose the child's head might come forth from the lower strait, without 
any extension, and with the chin still at the breast; but the pains 
now thrust the sagittal suture, in its whole length, indeed the entire 
crown of the head, against the elastic resisting perineum and posterior 
vaginal wall. The efforts, being often repeated, serve to push the 
perineum away from the crown of the pubal arch to let the vertex 
escape under it ; but, while the perineum is pushed off by this force, the 
same perineum jams the occipital bone of the child firmly against the 
crown of the arch ; so that, as the vertex emerges from the genital 
orifice, the os occipitis is pressed close to the symphysis, first at its 
lower edge, and next on its outer or front aspect. The cranium of 
the child is born as soon as the extension is complete, but not until 
then. 

Figure 27 exhibits the manner in which the vertex touches the 
inner surface of the crown of the arch 
when the rotation is complete. The Flg - 27 - 

faint lines show how it rolls out under 
the edge of the triangular ligament, and 
also how it rises upwards in front of the 
outer surface of the symphysis. 



Restitution. — As soon as the head 
is born, it begins to rotate back again, 
outside of the pelvis, to the same point 
or direction it had upon engaging within 
the pelvis. Its originally oblique posi- 
tion becomes restored, and this, which is 
the last act of mechanism, as to the head, is called the restitution 




Mechanism of the Shoulders' Delivery. — The cause of restitu- 
tion is to be sought for in the state or position of the shoulders. 



54 MECHANISM OF THE PELVIS. 

When the vertex is at the left acetabulum, the right shoulder is at 
the right acetabulum, and the left one at the left sacro-iliac synchon- 
drosis. But the inclined plane of the right ischium repels the de- 
scending right shoulder, pushing or sliding it downwards, forwards, 
and to the left, until it comes to the symphysis pubis. The left 
shoulder meanwhile falls into the open chasm of the hollow of the 
sacrum that yawns to receive it freely. 

This rotation of the shoulders, or, in other words, rotation of the 
trunk of the body, causes the act of restitution of the head, which, 
being born, must turn coincidently with the rotation of the shoulders. 

Such is the act, or rather such is the succession of acts, commonly 
called the mechanism of the head in labor, in which the vertex pre- 
sents in the first position. I shall now recapitulate them as predicated 
of a vertex presentation in the first position. 

1. Flexion.— The head becomes flexed; the chin going to the 
breast. It enters the pelvis obliquely, with the vertex to the left ace- 
tabulum. 

2. Rotation takes place because of the repelling resistance of the 
plane of the left ischium, the lessened resistance under the arch, and 
the incurvation of the hollow of the sacrum. 

3. Extension commences under the upward pressure of the peri- 
neum, and continues to increase until the child is born. 

4. Restitution allow T s the vertex to seek its original oblique direc- 
tion, in which it goes back again towards the left acetabulum. 

In treating of labors, and the conduct of them, I shall have nume- 
rous occasions to refer to, and further to explain, the mechanism of 
the passage of the foetal head. 

Mechanism of the Pelvis, with Vertex in Second Position. — 
In this labor the vertex is to the right acetabulum. In saying that 
the vertex is to the right acetabulum, it is not intended to convey the 
idea that the posterior fontanel is always directed absolutely against 
the acetabular region. Experience will soon teach even a young 
practitioner, that the child retains in early stages of labor the ability 
to rotate its head right or left, and that it generally exercises this 
faculty very freely, spinning its head upon the cervical spine so as 
to turn the vertex sometimes quite close to the symphysis pubis, and 
then whirling it back to the top of the ischium, or even as far 
backwards as the ilio-sacral junction. As the cranium, however, 
plunges deeper and deeper into the excavation, it becomes so tightly 




MECHANISM OF THE PELVIS. 55 

held that these rotatory motions cease, and it only moves in the direc- 
tion impressed upon it by the mechanics of the pelvis. 

The processes by which the vertex in a labor of the second posi- 
tion, as in figure 28, is brought forth, are the converse of those I have 
described as taking 

place in cases of first lg ' 

position. The flexion 
is followed by the ro- 
tation as the head 
sinks low into the cav- 
ity; the vertex being 
repelled towards the 
left by the inclined 
plane of the left is- 
chium. 

As soon as the pos- 
terior part of the sum- 
mit of the head reaches the perineum, the perineum, while it yields 
before the descending power, thrusts that body firmly upwards against 
the crown of the pubal arch, as in the first position. The extension or 
reversion of the head being completed by its expulsion, restitution takes 
place by carrying the vertex to the right acetabulum, outside, and the 
face is found to look to the left. The left shoulder turns to the right 
and forward to get under the arch, while the right shoulder goes to the 
sacrum, and so the shoulders are delivered ; sometimes the pubal 
shoulder is the first, and sometimes the sacral one is the first, to be 
expelled. 

Third Position. — The mechanism of the head, when the vertex 
presents in the third position, differs from the two just before de- 
scribed, only in the absence of the second act, the act of rotation. 

These third positions are very rarely observed ; and it is probable 
that w r hen they are met with, they depend upon a peculiar form of the 
superior strait. 

I have some pelves in which the antero-posterior diameter of the 
superior strait greatly exceeds the length of the transverse or oblique 
diameters. In such a pelvis it is obvious that the vertex would be 
more likely to present itself at the pubis, than at either acetabulum. 

In an ordinary conformation of the superior strait, a third position 
of the vertex presentation is extremely unlikely to occur, since long 
before the commencement of the labor, the prominence of the lumbar 



56 



MECHANISM OF THE PELVIS. 



vertebrae, and the overhanging promontory of the sacrum, would be 
almost sure to turn off the rounded forehead of the child into the right 
or left sacro-iliac region ; and this the more probably, inasmuch as the 
oblique being greater than the antero-posterior diameter, it affords an 
easy and inviting accommodation, as in the usual oblique mode of 
engagement. The three positions that have here been spoken of 
comprise the occipitoanterior positions of the vertex. They 
are those I have been accustomed to enumerate in the following order, 
viz., first, second, third, or, vertex left, vertex right, and vertex front 
positions. 

We have next to describe the fourth, fifth and sixth, or forehead 
left — forehead right — and forehead front positions of the vertex. 



Fig. 29. 




Fourth Position. — In the fourth position, the occipito-frontal diame- 
ter crosses the pelvis 
obliquely, as it does in 
the first position, with 
this difference, that its 
frontal extremity is at 
the left acetabulum, 
and its occipital pole 
at the right sacro-iliac 
junction. See figure 
29. 

This is a true ver- 
tex presentation; and 
it must not be mis- 
taken for a presentation of the forehead. It is a true vertex presenta- 
tion, because the chin is close to the breast, and there is no departure ; 
on the contrary, the flexion is, perhaps, even stronger than in occipito- 
anterior positions. 

The mechanical form of the pelvis is so miraculously adapted to 
the wants of the economy in labor, that it has power, in a major part 
of these fourth positions, to rotate the vertex from the right sacro-iliac 
junction to the right acetabulum, and thence to the pubal arch; and 
that without any assistance given by the accoucheur. 

It is true that this favorable rotation sometimes requires the aid of 
the hand, or even of an instrument, as shall be described on the pro- 
per occasion. It also occasionally happens, that neither the hand 
alone, nor any instrument, can enable the surgeon to bring the vertex 
round to the front. In such case, it slides into the hollow of the sa- 



MECHANISM OF THE PELVIS. 



57 



Fig. 30. 



crum, and the labor is thenceforward rendered more painful and more 
difficult. 

When, in fourth positions, the vertex can rotate first to the acetabu- 
lum, and then to the arch, the labor is not seriously retarded, and the 
mechanism thenceforth is the same as has been already treated of and 
described; but when the posterior fontanel gets into the hollow of the 
sacrum, and will not suffer rotation, then the flexion becomes greater 
and greater as the fontanel slides down along the point of the sacrum, 
along the face of the coccyx, and down the 
mesial line of the perineum, until, having 
pushed off the perineum 4.10, the occipito- 
frontal diameter, the vertex slips over the 
fourchette, and immediately turns over back- 
wards, in strong extension, which allows 
the forehead, eyes, nose, mouth and chin 
successively to emerge from underneath the 
crown of the pubal arch, to complete the 
birth of the head. The annexed figure (30,) 
of a head in an occipito-posterior position, 
shows these truths clearly enough. 

This is the mechanism in all cases of 
birth in occipito-posterior positions, without rotation to the front; and 
the student will clearly understand that it must be so, since the length 
of the line from forehead to vertex is too great to permit it to be 
otherwise. 




Fifth Position. — The fifth position, as in figure 31, is that in 
which the vertex is 

to the left ilio- sacral Fig - 31 - 

space, and the fore- 
head to the right ace- 
tabulum. Here, as 
in the fourth position, 
the mechanical form 
of the pelvis tends to 
turn the vertex first 
towards the left ace- 
tabulum, and thence 
to the arch. 




Sixth Position. — The sixth position finds the vertex at the pro- 



58 MECHANISM OF THE PELVIS. 

moratory of the sacrum. Madame Boivin met with only two such 
positions in 19,614 cases. 

I hare seen a greater number of sixth positions than were met with 
by that celebrated midwife, although the labors witnessed by her so 
greatly exceed in number all that I have seen. 

While the facts stated in her tables are to be relied upon for their 
historic accuracy, her statistical results cannot be admitted as the law 
of any practitioner's future experience. My own practice, for exam- 
ple, which has been a private practice, has shown me a far greater 
number of sixth positions than her vast clinical experience, in an im- 
mense Lying-in hospital, brought to her view. Madame Lachapelle 
saw no such case. 

A case of vertex labor in the sixth position occurred to me this 
day, of which I made the following note, in order that I might set it 
down here as a freshly remembered experience. 

Case.— July 8th, 1848, 10| A M. Mrs. E I , Pine street. 

This is the sixth child; a male, born fifteen minutes ago. The pains 
commenced moderately, at 4 P. M. yesterday, July 7th. Mrs. I. 
has been in pain at regular intervals all night. I arrived at quarter 
past nine, one hour since. The os uteri was nearly dilated; mem- 
branes unruptured. The anterior fontanel was touched through the 
membranes just behind the upper half of the symphysis pubis. By 
a strong pressure, I could conduct the index finger along the sagittal 
suture directly toward the sacrum, until I felt the triangular fontanel, 
leaving no doubt of the diagnosis. The left shoulder was at the right, 
and the right shoulder at the left ischium. The occiput was opposite 
to the top of the third segment of the sacrum; the flexion of the head 
was strong. 

Partly by pressing with my right index the right temple and zygoma 
towards the right; and partly by pulling with the same finger the 
right leg of the lambdoidal suture towards the left side of the pelvis 
and downwards, I converted this sixth into a fifth position. I now 
discharged the liquor amnii by rupturing the bag of waters. The 
next pain rotated the vertex to the left acetabulum, or first position, 
whence the vertex came forwards, and to the right, until it reached 
the arch, under which it began to extend, and was soon expelled. 

During the act of extension and expulsion of the head, and just 
before the whole head was completely born, an act of restitution com- 
menced. As soon as the head was free, the vertex went round again 



MECHANISM OF THE PELVIS. 



59 



to the sacrum, and the chin of the child rested with its under surface 
upon the front of the pudenda, the face looking upwards. 

This happened because the shoulders had not rotated at all, but 
plunged into the pelvis, the left one at the right, and the right one at 
the left ischium. 

With the next pain the left shoulder came to the arch, and the right 
one to the sacrum, and so they were delivered. The child was about 
seven pounds in weight. 

Here, then, was a clearly marked case of sixth position, notwith- 
standing which, the mechanical force of the pelvis and its strange 
adaptation to the form of the cranium, permitted me, with very slight 
assistance, to convert it into a fifth, and then into a first position. 
This rotation was fortunate for the mother; since, by effecting it, I 
prevented the necessity of a dilatation equal to the occipitofrontal 
circumference nearly, thus rendering necessary a dilatation equal 
merely to the bi-parietal circumference ; the former being nearly fif- 
teen inches, while the latter is not more than twelve inches. 

Face Presentation. — When the head presents in extension instead 
of coming down in flexion, we have presentation of the forehead, or 
of the face. If the extension be moderate, the forehead presents ; if 
it be very great, the face presents. When the face presents, it always 
comes down with the chin to one side, and the top of the forehead to 



Fig. 32. 



Fig. 33. 





the other side of the pelvis ; and it afterwards rotates the chin to the 
pubis or to the sacrum. In the case (Fig. 32), the chin is to the right 
ischium and the forehead to the left ischium. The natural movement 



60 MECHANISM OF THE PELVIS. 

of the mechanism would gradually turn this chin to the front of the 
pelvis, and the top of the forehead to the sacrum, as in Fig. 33. 

In face presentations the chin must be born first; see Fig. 33. 
Here observe that, from the chin to the vertex is more than five 
inches, while there is no diameter five inches long to be found within 
the true pelvis. Hence if the mental extremity of the occipito-mental 
diameter descends into the cavity before the occipital extremity, it 
must escape first from the outlet in order to allow the occipital ex- 
tremity to escape last, and vice versa. 

There are many cases of face presentations that appear to afford 
remarkably easy deliveries, and to require no aid from the hand. In 
all those, however, where assistance is demanded, there is an important 
doctrine, one that should never be lost sight of in the Conduct of the 
cases. The doctrine is this — Bring the chin to the pubis. The 
figure may show that, if the chin be brought to the pubis, it will have to 
sink only an inch, or an inch and a quarter, in order to get below the 
level of the crown of the arch. As soon as it reaches that point, it ad- 
vances beneath the arch, and thus the mental extremity of the occipito- 
mental diameter begins to be born. When this first step is effected, 
the whole length of that diameter is soon expelled, or, in other words, 
the whole head is born ; its occipital extremity being the last point 
that emerges from the ostium vaginae. 

Should any one, in practice, reverse this doctrine, and bring the 
forehead to the pubis, he would do a great wrong; for as the chin 
must be born first, and the occiput last, the chin will have to slide 
down the whole length of the sacrum, five inches ; and over the ex- 
tended perineum two and a-half or three inches before it can escape: 
but, to do this, it will be required that the head and half the thorax 
of the child shall be jammed together within the excavation; for, from 
the chin of the child to the top of its sternum are not eight inches. 
Such a position is almost sure to demand an embryotomy operation 
for the delivery of the foetus. 



PRESENTING PARTS THE HEAD. 



61 



CHAPTER III, 



OF THE CHILD S HEAD AND OTHER PRESENTING PARTS. 



Fig. 34. 



The study of the form and dimensions of the child derives its im- 
portance from the relations of the foetus to the bony pelvis, through 
which it is destined to pass in the act of parturition. 

To know the form and magnitude of the head, as related to the 
pelvic canal, is of the highest importance; and, indeed, no man 
should be looked upon as a qualified practitioner who suffers himself 
to remain ignorant of every particular of the matter now referred to. 

The foetal cranium, divested of the bones of the face, closely resem- 
bles in form an ostrich's egg, upon the side of the lesser pole of which 
the facial bones are adjusted. 

In the figure of the foetal head which is 
annexed (Fig. 34), it is evident that if the 
bones of the face were removed, the re- 
mainder of the cranium would be oviform ; 
as I have on different occasions shown it 
to be, by removing those bones in presence 
of my class at the Medical College. 

In looking at the head from above down- 
wards, as in Fig. 35, page 62, the bones 
of the face are out of sight, and the cra- 
nium is evidently egg-shaped, the greater pole being at the occiput, 
while the lesser is at the forehead. 

The foetal head (Fig. 36) is copied with the camera from a cast of 
a foetal head, and gives a proper idea of the true form when covered 
with its integuments. The child perished in the labor, its head being 
too large to pass through the straits without the aid of the forceps. 

The longitudinal diameter of this oviform skull has, by most au- 
thors, been computed at four inches, and its conjugate at three inches 
and a half; both of which calculations are considerably under the 
mark of truth, as I have found by careful measurement. 




fh 



63 PRESENTING PARTS — THE HEAD. 





The bones that enter into the composition of the skull, excepting 
the face pieces, are the os occipitis, the two ossa parietalia, the os 
frontis, the two ossa temporum, and the sphenoides. These are the 
bones that make up the principal bulk of the object, for the face 
bones do not add very considerably to the magnitude of the mass. 

The face bones are the maxilla inferior, the maxilla superior, the 
ossa malarum, ossa nasi, ossa palati, and the vomer. It seems hardly 
necessary to mention the ethmoides and the ossa unguis. 

In a neonatus, the process of ossification is not completed, and the 
edges of the cranial bones are not locked or dovetailed together by the 
serrse of the adult suture; whence it happens that the cranium is not 
a fixed magnitude or form, but is liable to change under the pressure 
of the parts through which it is driven by the great force of the labor- 
pains. 

A great advantage is found in this mobility of the cranial bones in 
certain instances, in which the pelvic circumference is too small, either 
absolutely or relatively; for, the child's head of four inches in its con- 
jugate diameter may become reduced or wire-drawn so as to pass 
through a superior strait of only three and a half inches, or even less ; 
and that without injury to the head, which, as soon as it has escaped 
from the pressure, begins to recover its normal form aeain. 

There are, on the other hand, to be met with certain specimens of 
the foetal cranium so solid and firm in their ossification as to yield not 
at all in labor, which is thus rendered both more painful and difficult. 
The young practitioner therefore should, in difficult cases, take com- 
fort from discovering by the touch that the foetal head is of a yielding 
nature, and hence not likely to resist too long the moulding or model- 
ing efforts of the throes, # 



THE HEAD. 63 

Diameters of the Fcetal Head. — In the foetal head at term, of 
which there is a drawing on page 61, we are in the habit of imagin- 
ing certain lines called diameters, which are there represented, in Fig. 
34. There is a line traced from the chin a, to the vertex or point 
of the head or occiput b, called by the English writers the oblique 
diameter, but which the French authors have induced us, of late, to 
denominate occipito-mental diameter, a phrase that explains itself. 
The next one is the line from d to e, called the occipitofrontal diame- 
ter, as indicating the distance from the occiput to the most salient 
point of the forehead. After this comes the perpendicular diameter, 
from c to h ; and lastly, in figure 35, page 62, the transverse or 
bi-parietal diameter, which passes from one parietal protuberance to 
the other, from a to b, and the temporal diameter, from c to d. 

As to these diameters, I have never deemed it expedient that the 
student should charge his memory with all of them ; yet he ought to 
know that the occipito-mental diameter is above five inches in length. 
He ought to know this, in order that he may also know that such a 
diameter cannot be see-sawed, or reversed, when the head has once 
fairly entered into the excavation, in which no space exists large 
enough to render such a change possible. If the extremity b descends 
first, it must escape first, or be returned above the superior strait ; 
and if the extremity a descend first, it must escape from the inferior 
strait first, or be returned above the linea ileo-pectinea, in order to be 
there see-sawed. 

The occipito-frontal diameter c a is four inches and ten-twelfths of 
an inch in length, — -a diameter too considerable to admit of its being 
see-sawed in the excavation, except under very extraordinary circum- 
stances, for there is, in general, not space sufficient for that end. 

I speak with very great confidence as to the above estimate, for I 
have carefully measured and recorded the size of three hundred crania 
of mature children that I received in the course of my obstetric prac- 
tice. The student will be in error if he adopts the common estimate 
of the authorities, which is too low at four inches. 

In a single series of one hundred and fifty heads, I found the occi- 
pito-frontal diameter in fifty-two of them to exceed 5 inches. In 11, 
it was SjMh; in 8, 5 T 2 2 ths; in 3, it was 5 T 3 2 ths; in 1, 5 T 4 2 ths; in 1, 
5 T 6 2ths; in 2, S^ths; and in 1, 5i|ths. 

The sum of my occipito-frontal measurements was seven hundred 
and twenty-nine inches and seven-twelfths of an inch for one hundred 
and fifty crania. The mean was four inches ten-twelfths. The sum 
of the bi-parietal diameters of the said one hundred and fifty crania 



64 THE HEAD. 

was five hundred and eighty-six inches and seven-twelfths — the mean, 
three inches and eleven -twelfths of an inch. 

The bi-parietal diameters exceeded four inches in sixty-eight of the 
children. In 19 it was 4.1 ; in 5 it was 4.2; in 6, 4.3; in 3, 4.4; in 
1, 4.5; in only one case was less than 3.6, the usual estimate, and in 
that case it fell to 3.4. 

A paper containing statements of the above series, was read by me 
at the centennial celebration of the Amer. Phil. Society, on the 25th 
May, 1843, and was published in the "Proceedings," &c, Vol. III., 
p. 127. 

I measured one hundred and twenty-six occipito-mental diameters 
of neonati at term, of which the sum was six hundred and ninety- 
nine inches and five-tenths, so that the mean or average of the one 
hundred and twenty-six diameters was five inches and a half. I know 
no one who has measured so many, and I am sure that greater accu- 
racy is not to be attained by any person. 

Upon these grounds, therefore, I am to inform the student that the 
occipito-mental diameter of the foetus is five inches and a half, the 
occipitofrontal four inches ten-twelfths, and the bi-parietal three 
inches eleven-twelfths. 

The above statements ought to show that it is not a matter of small 
moment whether the head presents in labor by the vertex, the crown, 
or the forehead. 

Upon the presentation depends the circumference of the advancing 
body — if the vertex presents, we have a circumference equal to thrice 
the bi-parietal diameter, which would equal a circle of eleven inches 
and three-quarters in circumference. The oocipito-frontal diameter 
would give a circumference of upwards of fourteen inches, while the 
occipito-mental circumference would not be much under sixteen inches. 

Fontanels. — The bones of the head are divided from each other 
by the sutures. In fig. 35, page 62, showing a top view of the 
skull, may be seen the sagittal suture, a straight line which ex- 
tends from the middle, and sometimes from the base, of the os frontis 
backwards to the upper edge of the occipital bone, where it appears 
to dispart, branching into the two legs of the lambdoidal suture. In 
passing from the forehead backwards, this sagittal or arrow suture 
crosses the transverse or coronal suture, and at the place of crossing 
there is a large vacuity, as to bone, which is occupied, however, by 
the skin and strong membranes which constitute what is commonly 
called the mould of the head — technically, the anterior fontanel, the 



THE HEAD. 65 

great fontanel, the frontal fontanel, or the bregma. It is of various 
size in. different specimens. When the ossification is precocious, it 
is small; in the contrary case it is large, and sometimes it is found to 
be very large. 

At the posterior terminus of the sagittal suture is found the poste- 
rior fontanel, often called the occipital fontanel. 

There is a very great difference between the anterior and the pos- 
terior fontanels. The former being quite large, quadrangular, and 
yielding to the pressure of the finger; the latter being so small that it 
can only be distinguished by the three suture lines that radiate from 
a common centre. Let the student carefully learn to make this dis- 
crimination, for if he should not do so, he will in practice find himself 
embarrassed in his diagnosis of the two fontanels. 

Too much care can hardly be bestowed upon the mastering of 
these two points; nor can one become too familiarly acquainted with 
the differences between them ; for, in trying to ascertain the precise 
position of any head-presentation, the accoucheur always seeks to 
place his index finger upon one or the other of these openings. It is 
clear that they must serve as points of departure in an exploration, — 
for if the index finger be in contact with the posterior fontanel, and 
the place that finger occupies in reference to any fixed point in the 
pelvis be well understood, the surgeon ought thence to deduce the 
very place of any and of every part of the cranium of the foetus. To 
know w T here the fontanel is, is to know where to conduct the hand, 
the forceps, the perforator, or the crotchet. 

It has been seen, in a preceding page, that the various positions 
assumed by the head w T hen it presents in labors, are enumerated, as 
first, second, &c, and that they are determined by reference to the 
points on the pelvis to W'hich the posterior fontanel is addressed. 

Presentations. — The student who shall have made himself master 
of the subject of the pelvic diameters is now enabled to appreciate the 
differences that arise in labors exhibiting unfavorable presentations or 
the head. He knows that the bi-parietal circumference of the head 
is not too great to admit of its ready transition through the excava- 
tion — and he as clearly understands that the occipitofrontal or the 
occipito-mental circumference w T ould prove too large for the canal. 
Therefore, in any case of delay or difficulty, he w 7 ould provide for 
effecting a coincidence of the bi-parietal circumference with the planes 
(of the excavation) through which it must necessarily pass. 

If the pelvis be four and a-half inches in its antero-posterior dia- 
5 



66 



THE HEAD. 



meter at the superior strait, the occipital pole of the occipitofrontal 
diameter must dip so as to allow the vertex to descend, and thus be- 
come the presenting part. In fact, the foetus lies so packed up in the 
womb that it may be said to be in a state of universal flexion — the 
legs are bent upon the thighs, the thighs upon the trunk; the arms 
and forearms and the whole spinal column are in flexion — so that 
even the head is found to be flexed as a normal condition of the foetus 
in utero. 

The drawing exhibits very naturally the usual presentation and po- 
sition of a child at the beginning 
Fig. 37. of a labor. It represents the 

womb opened, with the foetus in 
w r hat is called a vertex presenta- 
tion in the first position; i. e., the 
posterior fontanel is turned to- 
wards the left acetabulum of the 
mother's pelvis, and the vertex, 
or occipital pole of the cranium, 
dips sufficiently to allow of its 
entering the pelvis through the 
plane of the superior strait. 

The drawing also shows how 
very much the spinal column is 
curved. It is manifest, that if 
pressure should be made upon 
the pelvic extremity of the co- 
lumn, in a direction from above 
downwards, it would be still more considerably bent — it would be an 
elastic resisting arch ; and the outward thrust of the cervical extre- 
mity of that arch would tend to flex the head, more and more, in pro- 
portion to the increasing violence of the thrusting effort, so that the 
lower the head descends, the more must the chin be pressed against 
the breast, and the more perfect the coincidence of the bi-parietal 
circumference with the planes of the excavation through which it 
happens to be passing. 

Unfortunately, the occipital extremity of the occipito-frontal diame- 
ter does not always dip, and the frontal extremity of it is sometimes 
found to be the dipping pole. In such an instance, the chin is said 
to depart from the breast, and we encounter a presentation of the 
crown of the head, the forehead, or even of the face, the head in the 
last named case becoming completely extended, instead of de- 




THE HEAD. 67 

scending in flexion . But the account of these accidents must be 
deferred until we come to treat of those special presentations, which 
we hope to be able fully to explain and describe. 

The child at full term is about nineteen inches in length. Speci- 
mens are occasionally met with of children twenty-one inches high ; 
but they are rare. 

The average weight of a new-born child is somewhat about seven 
pounds — very many of them weigh eight pounds, and it is by no means 
a rare occurrence to find a child weighing nine, ten, eleven and twelve 
pounds at birth. 

I have never seen one yet that weighed fourteen pounds. The 
largest one I have weighed was thirteen pounds and a half avoirdu- 
pois. The mother soon afterwards perished with inflammation of the 
womb and bowels. To witness the birth of such a monster is appal- 
ling. I have heard of children of seventeen, and even of eighteen 
pounds weight at birth. Such relations always lead me to suppose 
that some mistake has occurred in weighing the infant. M. Velpeau 
justly remarks, that children of that weight are children of three 
months old, and that such magnitude is impossible at birth. My own 
clinical experience, which has been very abundant, has never enabled 
me to see a child of fourteen pounds weight at birth. 

The head of the child exceeds, in its smallest circumference, the cir- 
cumference of the thorax and shoulders, or the abdomen or the hips; 
wherever the head can pass, there will, therefore, be space for the 
transmission of the body. 

The length of the child, folded up in the womb in flexion, is about 
eleven inches from the summit of the head to the lower extremity of 
the pelvis, or buttocks. 

In about forty-nine out of fifty cases of pregnancy, the head is at 
the os uteri — in one out of fifty cases, the pelvis is at the os uteri, 
giving us the breech, feet, or knee presentation. 

When the head presents in labor, it is to be supposed that it has 
presented during the entire gestation, and vice versa. 

The vulgar notion that the child lies in the womb with its head to 
the fundus until labor is about to commence, and then turns his head 
downwards to the mouth of the organ, in order to escape head foremost, 
is erroneous — for the child is eleven inches long, and cannot turn it- 
self in a womb only seven or eight inches in conjugate diameter. If, 
in like manner, the breech presents in labor, we infer that it has pre- 
sented for many months antecedent to the commencement of the par- 
turient efforts. 



68 



PRESENTATIONS. 



Hippocrates said the child is packed up in shape like an olive in 
a narrow-necked flask — if one or the other pole of the olive presents 
itself to the aperture, it may escape ; otherwise, it must be broken, or 
the flask must be broken, in order to extract it. 

The same is true in midwifery. Either the cephalic or the pelvic 
pole of the foetal oval must descend, in order to its birth; and it is a 
matter of little moment which should be the pole, whether the cephalic 
or the pelvic, all other things being equal. 

Upon the whole, the head presentation is the most favorable for both 
mother and child, since nature provides that it shall occur in the ratio 
of forty-nine to fifty in frequency. 



Fig. 38. 



Two Presentations only — Cephalic and Pelvic. — Rigorously 
speaking, there are but two presentations in midwifery: one of the 
head — the other of the pelvis. 

As to the head presentation, it may deviate, and allow a shoulder to 
come to the os uteri ; but this is an accident of a cephalic presentation : 
an accident that has arisen from the impinging of the head upon 
the margin or brim of the pelvis, whence it has glanced upwards to 
the iliac fossa, permitting the shoulder to take its place. This is to 

be seen by inspecting the cut, in which 
the child's head, which originally pre- 
sented, has deviated, and gone above 
the plane of the superior strait, lodg- 
ing itself in the left iliac fossa, while 
the shoulder has come to the strait, 
and allowed the arm to prolapse. 

The cut may serve to show how the 
hand and arm have merely prolapsed ; 
making what is commonly denominat- 
ed an arm presentation — but is it not 
clear, the head having gone up, that 
the shoulder still really presents, and 
that the arm has merely fallen down, 
or prolapsed? 

From the above, it appears that we have — 
1st. Cephalic presentations ; 

2d. Cephalic presentations deviated, with descent of the shoulder; 
and, lastly, 

3d. Cephalic presentations deviated, with descent of the shoulder, 
and prolapse of the arm. 




PRESENTATIONS AND POSITIONS. 



69 



Fig. 39. 




Here is a drawing representing a breach presentation, or presenta- 
tion of the pelvic extremity of the foetal oval. This is the second normal 
presentation of the child, the cepha- 
lic being the first. In this case, an 
accidental deviation might cause the 
buttock to glance upwards on the 
brim of the pelvis, to take its lodg- 
ment in the left iliac fossa. Such 
an accident would give rise to a 
footling labor, or to a presentation 
of the knees. 

A footling presentation, then, is 
only an accident happening in the 
course of a pelvic presentation — and 
the same may be said of the knee 
cases, which are very rarely met 
with. 

I recommend these views of presentations to the medical student, 
who, if he should adopt them, will find his notions of midwifery greatly 
simplified, and his memory not loaded with useless divisions and de- 
scriptions that serve only to embarrass him as a student and perplex 
him as a scholar or practitioner. 

These are the divisions I have proposed in my public Lectures ; and 
having found them convenient also at the bedside, 1 with confidence 
advise him to prefer them to the long catalogue of presentations in 
the books. Knowledge in its nature is simple, pure, not complex ; 
it owes its seeming complexity and abstruseness only to man. 

• If the student should ask me where I will place the presentation of 
the belly and the back of the foetus, I cannot reply, for I do not know 
whether they be derived from deviations of the pelvis or from deviation 
of the head. I am sure, however, that all such cases are accidents of 
the cephalic or of the pelvic presentation. 

The word presentation refers to the part of the foetus nearest the 
os uteri or excavation. 



Positions of a Presentation. — The word position refers to the 
relation between a certain part of the presentation, and a certain part 
of the pelvis. Thus in vertex presentations, the posterior fontanel 
may be in the fifth position, that is to say, the occiput of the child 
may be directed to the left sacro-iliac junction, and its forehead to the 
right acetabulum. 



70 PRESENTATIONS AND POSITIONS. 

Care should be used to avoid confounding the terms presentation 
and position. 

There are six positions of the vertex presentation. 

1st. Vertex to the left acetabulum. 

2d. Vertex to the right acetabulum. 

3d. Vertex to the symphysis pubis. 

4th. Vertex to the right sacro-iliac junction. 

5th. Vertex to the left sacro-iliac junction. 

6th. Vertex to the promontory of the sacrum. 

There are four positions of the pelvic presentation. 

1st. Sacrum to the left ischium. 

2d. Sacrum to the right ischium. 

3d. Sacrum to the pubic symphysis. 

4th. Sacrum to the promontory. 

In the shoulder presentations there are four positions, two positions 
to each shoulder. 

Right shoulder presentation ; the head is in the left iliac fossa, 
the face looking backwards. 

Right shoulder presentation; the head is in the right iliac fossa, 
the face looking forwards. 

Left shoulder presentation, the head to the left looking forwards. 

Left shoulder presentation, the head to the right, looking back- 
wards. 

These being the principal presentations, with their several 
positions, I shall enter into full details of them when I come to treat 
of the special labors in which they require to be managed by the 
accoucheur. 



GENITALIA. 71 



CHAPTER IV. 



THE ORGANS OF GENERATION. 



The organs of generation are divided into external and internal, the 
latter terra being applied to those that are contained within the 
cavity of the pelvis, and the former referring to those that appear upon 
the external surface of the pelvis. 

The external sexual organs, in the aggregate, are indicated by the 
word Pudenda; a word very happily selected as a reference to, rather 
than a direct denomination of, a part of the body which the sex, with- 
out exception even of any barbarous tribes, endeavor modestly to 
conceal from every eye. We are told that the first sinful indulgence 
of the human appetites was succeeded by the deepest consciousness 
of exposure, upon this subject, and the fig-leaf, which concealed the 
shame of the first woman, is a simple expression or emblem of female 
delicacy: the Venus de Medici is not less an expression of female 
modesty than of the utmost perfection of the female form : its modesty 
is the key to that inimitable, absolute and pervading beauty, which 
places it at the head of the ancient works of art, and renders the 
statue at once a truth in morals, and a profound homage to one of 
the best attributes of woman. 

Notwithstanding the aversion of females to every allusion to the 
pathological or obstetric affections of these organs, it is unavoidably 
incumbent on the practitioner to make himself acquainted with their 
anatomical structure, since they are the seats of diseases and acci- 
dents, and the agents of pathological and surgical processes, which 
the practitioner is often called upon to superintend ; and it would be 
the grossest injustice to the female patient, to assume the conduct of 
some of her sexual disorders, without a perfect preparation for the dis- 
charge of duties which, by their importance, necessarily take prece- 
dence of those considerations that, under other circumstances, it would 
be both wicked and disgusting to pretermit. Let the student of mid- 
wifery, therefore, experience no sentiment at variance with the mens 



72 GENITALIA. 

sibi conscia recti, in turning his attention to this portion of our sub- 
ject. 

Pudenda. — The surface of the body which is found in front of, and 
just above the symphysis of the pubis, is raised so as to present the apr 
pearance of a protuberance, which, at the period of puberty, is covered 
abundantly with hair, and has received the denomination of Mons 
Veneris. The cutis, which covers this part, is supplied with numerous 
sebaceous follicles, and is ordinarily of a darker color than the general 
superficies. The size of the protuberance varies in different indivi- 
duals, being greatest in those who are fat, and partially disappearing in 
those who are much emaciated, while the projecting ossa pubis upon 
which the mons is constructed, serve, in all cases, to lift it upwards 
above the general level of the surrounding parts. The subcutaneous 
structure is largely supplied with an adipose deposit, contained in cells 
connected by so dense a tissue, that inflammations and abscesses 
occurring within it, are rendered remarkably painful, as is the case 
in all such affections occurring in unyielding textures. 

Vulva. — A little below the top of the pubic symphysis commences 
the genital fissure, which is most commonly designated by the term 
Vulva. 

Labia Pudendorum. — The parts which are separated by this fissure 
are called the Labia Pudendorum, or Labia Majora. They are composed 
of skin, which is disparted at the inferior portion of the Mons in order 
to admit of this construction, the division extending downw r ards to the 
lower extremity of the vulva, where it terminates in the inferior commis- 
sure of the vulva, at the anterior edge of the perineum. The labia, which 
consist, externally, of cutis in all respects similar to that of the Mons, 
and, like it, covered with hair, are lined, internally, with an epithelium, 
that serves to protect the mucous surface beneath. The basis of their 
structure is a rather loose cellular tela, supplied less abundantly than 
the part above with adipose cells, and therefore liable, under circum- 
stances of dropsical infiltration, of extravasation, or inflammation, to 
a great degree of swelling. The labia, since they serve as the outer 
limit of the vulva, are also liable to a great degree of elongation, or 
distension, during the transit of the child in parturition. This dis- 
tension is so great that it equals a circle of about ten or twelve inches 
in circumference. As the superior commissure of the vulva is found 
at least one inch above the bottom of the symphysis pubis, and the 



GENITALIA. 73 

foetal head passes out between the top of the pubic arch and the infe- 
rior commissure of the vulva, the student will appreciate the very 
great extensibilhy of the labia majora; nor will he experience any 
surprise upon being informed that a great force is required to over- 
come their resistance ; that much time is often consumed for that 
end ; or that the labia are occasionally ruptured before they become 
sufficiently extended to admit of the escape of the head. I have seen 
several instances in which one labium was broken transversely 
during the transit of the head in a first labor. No evil consequences 
ensued in those instances, the wounds uniting by the first intention, 
or more slowly healing by the process of granulation. 

Labial Thrombus. — When the labia are put excessively upon the 
stretch, it occasionally happens that some of the ischiatic vessels, 
with which they are abundantly supplied internally, give way, and 
that a quantity of blood is soon poured out into the cellular tissue 
within. The extravasation may amount to only a teaspoonful, or may 
equal half a pound. Of course, in such a case, the labium must be 
greatly swollen, and of a dark color, causing very severe pain, or 
even sloughing of the part. The swelling is generally discovered 
soon after the conclusion of the labor, rarely before the labor is over. 
I have recited the circumstances of an interesting case of this labial 
thrombus, in my letters on Females and their Diseases, p. 65, to 
which I refer both for the case and for extended remarks upon the 
accident generally. 

When the occurrence of a rupture of vessels, pouring the blood into 
the texture of the labium, is discovered, it is proper at once to take 
certain precautions. The blood may be removed by making a free 
incision, to be practised upon the internal surface of the labium ; 
which indeed will be most easy to come at, because, in extensive 
swellings of this part, there is always eversion of the labium and not 
inversion, in consequence of the greater density of the cutis. The 
same thing is observed to happen in swellings of the lips, which seem 
to be then everted, as also in swellings of the eyelids, where some 
degree of ectropium is a common result of great distension. 

(Edema Labiorum. — Pregnant women are frequently afflicted with 
oedema of the lower extremities ; the swelling, in some examples, 
extending up along the thighs, when the watery infiltration causes a 
great distension of the labia soon after the fluid reaches them. I have 
seen a case in which, notwithstanding antecedently to the approach of 



74 GENITALIA. 

abor, I punctured the labia repeatedly, so as to permit the serum freely 
to escape, the labia and perineum remained so swollen and hard, as 
to produce the highest degree of embarrassment during the parturient 
efforts. The student will perceive how greatly inconvenient it must be 
to have the whole perineum and labia pudendorum not only swelled, 
but hardened by the pack of the serum within their loose cellular mem- 
brane. Such a state is most particularly to be deprecated, when we 
have occasion to resort to a forceps operation. In a forceps operation, 
where the head is still inconveniently high in the pelvis, a thickened 
and rigid perineum is a deplorable obstacle. I have met with a case 
of the kind that wholly baffled all attempts to adjust the forceps — for 
the posterior commissure of the vulva could not be made to go far 
enough backwards to enable me to lock the joint of the instrument, 
and I was, at last, with the concurrent opinion of the late Professor 
Dewees, compelled to perform an embryulcia operation. 

I have met with numerous cases in which the perineum, as well 
as the labia, being thickened, the pressure of the descending child 
soon and easily dispersed the waters of the infiltration: nevertheless, 
I think that in all instances where the swelling is great, several punc- 
tures should be made with a lancet, towards the close of pregnancy, 
in order to permit the fluid to escape. A lesser degree of tumefaction 
does not demand so unpleasant a remedy, the water of the cellular 
tissue being readily pressed out by the advancing head, and dispersed 
into other portions of the cellular texture in the vicinity of the vulva. 
The punctures may be very safely made, and the operation gives no 
great pain. 

Labial Abscess. — The labia, occasionally, are the seats of ab- 
scesses that are excessively painful. They always point towards the 
inner surface. For the most part, they suppurate rapidly, and should 
be opened as soon as a deposit of pus can be ascertained to exist. 
Few instances will probably be found in which the medical attendant 
shall be able to discuss such inflammations, since their location deters 
the female from calling for his aid until intolerable pain or inconve- 
nience compels her to do so; and since, at such a stage, suppuration 
will, for the most part, be found inevitable. 

Whenever it is deemed practicable to effect a resolution of such 
inflammation, it ought to be attempted, for we know not what 
change of structure may take place, in consequence of abscesses in 
the labia. Whatever causes tend to affect the labia with permanent 
alterations of their form or density, are to be always carefully obvi- 



GENITALIA. 75 

ated, since the part they perform in labor is highly important. A 
bleeding from the arm, followed by leeches to the part, and fomenta- 
tions with decoction of linseed, saturnine applications, &c, will be 
proper, upon the institution of an attempt to discuss an abscess in the 
labium. 

Cohesion of the Labia. — In young children it not unfrequently 
happens that the inner face of the labia pudendorum becomes irri- 
tated, which produces an adhesive inflammation, uniting the surfaces 
that are in mutual contact. The inevitable evacuation of the blad- 
der will, of course, always prevent a union of the whole extent of the 
labia. 

In all the instances of this kind that have fallen under my notice, I 
have found it sufficient to separate the cohering surfaces by forcing them 
apart with the fore and middle fingers of the left hand, while, with the 
end of a probe, drawn down directly upon the line of union, the adhe- 
sions are easily destroyed, and that without occasioning the least 
bleeding. The scalpel has never been required. In performing this 
operation in a good light, it will be seen that the union of the surfaces 
has taken place by the mutual interlocking of very delicate villi, much 
in the same way as the placenta and cotyledon of the sheep or cow 
are interlocked. The villi that are pulled apart in this process are ex- 
ceedingly delicate. I have been struck with this resemblance on seve- 
ral occasions. I have no doubt, however, that a case might occur, in 
which, by long neglect, the union should acquire so great a degree of 
solidity as to yield only to the knife. 

When the labia shall have been separated, in these instances of 
cohesion, they should be carefully kept from coming in contact by a 
pledget covered with cerate, as the adhesive tendency is renewed by 
the very violence which is required to obviate the consequences of a 
preceding irritation. 

M. Colombat, in his Treatise on the Diseases of Females, advises 
us to touch one, not both, of the recently separated surfaces, with a 
nitrate-of-silver-pencil in order to produce on that surface a state of 
vital action different from that existing on the uncauterized surface ; 
which he supposes must effectually obviate the tendency to cohesion. 
His idea is, that to adhere, both surfaces must possess the same adhe- 
sive temper. For my part, I have found it in all instances sufficient 
to direct the nurse to draw the point of the little finger, dipped in oil, 
strongly downwards, from the anterior to the posterior commissure. 



76 GENITALIA. 

Such a process, daily repeated, effectually sets aside all possibility of 
re-establishing the cohesion of the labia. 

Differences of the Labia. — The appearance of the labia in vir- 
gins, is different from that observed in females who have borne chil- 
dren. In the latter, they present a somewhat shriveled or collapsed 
appearance, except in fat persons; and the inner surface, which in 
virgins is of a rose tint, becomes bluish or black in the aged, or those 
who have had children. The inferior commissure, also, is lower down 
in women who have borne children; whereas, in the virgin state, the 
lower commissure crosses the pubis almost as high up as the top of 
the triangular ligament. This is found to occur in most young 
females, examined early, in a first labor. 

The Nymphs. — The Nymphse are also called labia — labia minora, 
labia interna. They differ from the greater labia in that they consist 
of a duplicature of the mucous membrane, covered with a strong epi- 
thelial surface, and containing an erectile tissue ; whereas the greater 
labia have a basis of adipose texture possessing no erectile structure. 
In young persons, excepting neonati, the nymphse are wholly concealed 
within the genital fissure; but in those who are somewhat advanced in 
age, and who have borne children, one of them may be commonly ob- 
served to protrude beyond the vulva, a circumstance which depends 
not more upon a change of its proper structure, than upon the shrink- 
ing of the labia consequent upon advancing age and repeated par- 
turition, as has been already mentioned. The top of the nymphse is 
but little below the superior commissure of the vulva, and each nym- 
pha descends obliquely outwards, generally, terminating rather more 
than half way down the labium of each side. This arrangement gives 
it the appearance of a pointed arch. 

The color of the nymphse, in young persons, is a lively red ; they 
are thin, and their surface is not corrugated ; w T hereas, in women who 
have borne children, they assume a darker hue, and are sometimes 
observed to be very much thickened and corrugated, not unfrequently 
presenting a lobulated appearance. Haller informs us that hairs are 
occasionally found to grow upon them. They are supplied with a 
peculiar kind of sebaceous matter, which, in uncleanly individuals, 
accumulates in considerable quantities, giving rise to a disgusting 
fetor. 

It is useless to inquire into the motives for bestowing upon this or- 
gan a title which appertains to the Divinities that preside over foun- 



GENITALIA. 77 

tains. It is at least certain that these bodies exercise no influence 
over the sources or direction of the urine. It is asserted that they 
subserve a very important end, to wit, the supply of an additional 
material for the distensions which these parts undergo in the last mo- 
ments of labor, thus diminishing the risk of rupture of the external 
parts of generation. I have, however, repeatedly ascertained, that at 
the instant of the extremest distension of the vulva, the nymphse are 
not effaced, but can be distinctly felt, like a firm ridge, little less ele- 
vated or marked than in the most entire repose of the organs. It is 
easy to verify this fact in any case of labor. 

There is high authority for the assertion that they are the subjects 
of erection under the excitements of the sexual passion, and possibly 
they may concur, therefore, in the production of the orgasm which 
seems essential to conception. It is proper to say, however, that the 
uses of the nymphse are unknown. They do not exist in any other 
species of mammalia. 

Notwithstanding that the fold of the nympha is not effaced or flat- 
tened out in labor, it sometimes happens, that, while contingently 
elongated by the extension of the labia, they suffer laceration. Like 
all other living tissues, they are obnoxious to inflammatory diseases, 
which are often extremely painful. The treatment of abscesses of 
these parts is conducted upon the same principles and indications as 
occur in those of the labia majora. 

In some cases of young children, the anterior edges of the nymphse 
become coherent from an adhesive inflammation developed in thern. 
If the cohesion extend far downwards, the two nymphae form a sort of 
curtain or flap in front of the urethra. This accident causes the urine, 
which cannot flow off pleno rivo, to dribble over the surface of the 
vulva and perineum, giving rise to painful excoriation. In a specimen 
mentioned by Colombat, the upper portions of the nymphse had not 
cohered, while the lower portion obstructed the urine and compelled it 
to rise upwards to escape beneath the clitoris. This gave rise to a 
urinary distress which was only relieved by the surgical separation 
of the cohering margins. M. Colombat cites several interesting 
cases of the kind. 

In those individuals in whom they protrude beyond the external 
surface of the vulva, excoriations of them are occasionally met with. 
Where such excoriations are rebellious under treatment, it is best to 
remove the protruding portion by the scalpel or scissors. This ope- 
ration may be safely resorted to, since it is a prevalent custom among 
many tribes of Arabs and Moors, and also the Coptic inhabitants of 



78 GENITALIA. 

Egypt, to apply the rite of circumcision, or rather excision, to the 
young female. 

It cannot be needful, in a work so limited as this, to enter into in- 
vestigations concerning the so much talked of tablier des Hottentotes. 
For an ample account of the subject, I refer the curious student to 
Mr. Lawrence's Phys. and Zool. of Man, page 420, where a very 
considerable number of authorities may be found. M. Merat's remarks 
on the same subject may also be examined, sub voce, in the Die. des 
Sci. Med. 

An account of the Hottentot apron maybe found also in the Annals 
of the Museum, of Natural History. It was furnished by M. George 
Cuvier. There is no reason to suppose it is a case of hypertrophy. 
All travelers in Southern Africa now agree that it is an ethnographical 
characteristic of the Bushman women. 

The Clitoris. — The word clitoris, according to De Graaf, in his 
Treatise de Mul. Org. Gen. Inservientibus, p. 16, is derived from 
x%ntopi%eiv quod hanc partem lascive fricare ac contrectare significat. 
It is the organ of touch for the aphrodisiac sense. 

The tip of the clitoris juts out under the summit of the pointed arch 
formed by the union of the upper ends of the nymphae. The clitoris 
possesses very considerable analogy to the male penis : it consists of 
two corpora cavernosa possessing two crura, which, like the crura of 
the male penis, are attached to the ossa pubis ; and the analogy may 
be further prosecuted, by attending to the manner in which the deep 
crescentic fold of the upper part of the nymphse surrounds the apex 
of this organ. This fold is called the preputium clitoridis. The cli- 
toris differs from the male penis in that it possesses no corpus spon- 
giosum, and of course it can have no real glans, or urethral canal. 
It is erectile, and is endowed with the most intense erotic sensibility. 
The uses of the organ are probably to be sought in this peculiar 
endowment. Its asserted universal occurrence in the mammalia 
bespeaks its importance. 

I could never discover a clitoris in many females of the Didelphis 
Virginiana that I have dissected with a view to discover it. 

J. Miiller, at p. 1464 of his Physiology, has a paragraph on the sub- 
ject of the clitoris, in which he says, "that the clitoris of the mammal 
is of the same structure as the penis of the male embryo, both of them 
being formed upon the same principle of development. The embryo 
clitoris and the embryo penis at first resemble each other exactly, as 
to their external form. The corpus cavernosum is open or cleft, in 



GENITALIA. 79 

both alike, so as to form an open canal. Both have muscles, ischio- 
cavernosi, and constrictores pudendi ; but, when the perineum closes, 
in the progress of development, in the male embryo, the latter muscles 
become acceleratores urinse. The clitoris becomes shorter, and the 
lips of its groove become converted into nymphse." 

Rudolph Wagner says, " that the generative organs are late in 
making their appearance, even later than the kidneys and supra-renal 
capsules. There is no trace of them at the end of the first month. 
The canalicular cleft of the penis is closed at the first month, and 
becomes the urethra. On the contrary, the edges of the cleft rise 
more and more, and become converted into nymphse in the female. " 

Here I may venture to remark that this law of development does 
not apply to the mammiferous quadrupeds, who are wholly destitute of 
nymphse. If the observations of the physiologist above named were 
correct, we should be at a loss to account for the failure of the 
analogy. ♦ 

The clitoris is the subject, in some individuals, of so great a degree 
of hypertrophia, that it comes to bear a marked resemblance to the 
male organ. Such affections, doubtless, are the causes of a prevalent 
vulgar belief in the existence of hermaphrodites. The cases of mo- 
noecious vegetables and of some annelides, as the earth-worm and other 
inferior creatures, may be cited as examples of the double sex in an 
individual constitution. The Indian corn, for example, fecundates 
by its male organ its own female germ. But, notwithstanding that 
monoecious plants, and some of the lower orders of the animal king- 
dom, contain within their bodies the organs of a double sex, we are 
not authorized to admit that a similar condition can occur in beings 
of a highly complex organization, where an entire individuality of the 
male and female is and must be indispensable. The prayer of Sal- 
macis, that her lover's body and her own might be united into a 
single one, although granted by the mythological divinities, leaves 
the sexual individuality both of Salmacis and Hermaphroditus unde- 
stroyed ; and so must it always be in nature. 

Wherever suspicions are entertained of the existence of an herma- 
phrodite, it will probably be found that an enlarged clitoris, or a bifid 
scrotum, presenting the appearance of labia pudendorum, has given 
rise to the suspicion. 

The Urethra and Vestibulum. — Just on a line with the top of the 
pubic arch, is a small bulbous projection, which encloses the orifice 
of the urethra : the triangular space included betwixt this bulb, the 



80 GENITALIA. 

nymphse and clitoris, is called the vestibulum. It is important to 
understand its position, because it is always referred to in introduc- 
ing the catheter, which is very easily performed if one has a correct 
knowledge of this part, and very difficult of execution in the absence 
of such knowledge. The lower part of the vestibulum is divided ver- 
tically by a raised line or raphe, which can be readily felt with the 
point of the finger, and which leads directly to the orifice of the 
urethra, to which it should serve as a director in the operation above 
mentioned. 

The female Urethra is from an inch and a half to two inches in 
length. It turns upwards and backwards, directly under the triangular 
ligament of the pubis, at the base of the triangular space above called 
vestibulum. In introducing the catheter, the point of the tube should 
be directed perpendicularly to the surface of the vestibulum, and in- 
troduced within the orifice of the urethra, and then, by depressing the 
handle, the point will turn upwards behind the pubal bone towards 
the orifice of the bladder. Notwithstanding the female urethra is so 
short, it often happens that the bladder, when much distended with 
urine, and particularly during labor, is carried very high upwards, so 
that the urethra is much elongated. I have several times been obliged 
to introduce the catheter fully four inches, before it would enter the 
bladder of urine. The urethra is also very much elongated in some 
cases of retroversion of the womb. 

On account of the situation of the urethra, it is sometimes subjected 
to so severe a degree of pressure by the foetal head, that it sloughs 
before or after delivery, and gives rise to the distressing symptoms of 
urethro-vaginal fistula. It is also subject to contusion and laceration 
in some of the forceps or crotchet operations; accidents that cannot 
be too carefully guarded against by every humane or considerate 
practitioner, as entailing upon the patient the most distressing stilli- 
cidium of urine. 

The Hymen. — The Hymen is a fold of the mucous membrane of the 
genital surface, of the nature of a valvula connivens. It is a crescent, 
with the cornua directed forwards and upwards. It is situated just 
within the entrance of the vagina; and is ordinarily so thin and delicate 
as to yield to a slight force ; whence it is often found to be wanting in 
adult persons, having probably been ruptured during infancy or child- 
hood. Certainly there are many very young subjects met with in 
the anatomical rooms, in which no trace of it is to be discovered. 
The fold of mucous membrane of which it is composed, is broad in 



GENITALIA. 81 

some, and very narrow in others. I am well convinced that I have, 
in many instances, met with the unruptured hymen during my ob- 
stetric practice. I may venture to assert, that whoever attends a great 
many women in first labors will have occasion to observe the ex- 
istence of a very narrow hymen in many such persons. I make 
this statement, not unaware that I may be charged with having mis- 
taken the fourchette for the organ in question. I think, however, 
that my opportunities in midwifery practice for acquiring experience 
have been sufficiently ample to warrant me against the commission of 
so gross an error. 

In some individuals, the hymen is not crescentic, but circular, with 
an opening in the centre, or in some other part of the plane ; and a 
few examples are met with in which the hymen is imperforate. I 
refer to page 94 of my Letters on Females and their Diseases, for a 
case in which the hymen formed a diaphragm in the vagina. 

Instances are also recorded of such firmness in the tissue, that 
incisions have been required in order to allow of the delivery of the 
foetus, which, by the resistance of the hymen, was prevented from 
being born. 

The foregoing should serve to convince the Student, that, as a test 
of virginity, this organ cannot be relied on, since it is often wholly 
wanting ; so slightly developed as to oppose no resistance in coitu, or 
even in labor ; and on some occasions, so strong as to require the aid 
of the surgeon for its destruction. 

The barbarous practices of some of the African nations, are worthy 
only of a barbarous people, and the distressing suspicions and doubts 
which sometimes are connected with vulgar errors on the subject of 
the hymen, ought, if possible, to be exploded. It appears to me to 
be the duty of the physician to speak in positive terms, and, when- 
ever suitable occasions offer, to reprobate so useless and often inju- 
rious a dogma. 

Fourchette — Fossa Navicularis. — A space that exists between 
the Fourchette, which is the inferior commissure of the labia, and the 
hymen, is called the Fossa Navicularis. The fourchette is a pretty 
firm fold of the tissues, serving to unite the lower extremities of the 
vulva. It is said to be generally ruptured in a first labor, which I do 
not think is true. It is doubtless often broken, and no evil conse- 
quences commonly ensue from the accident. 

The Perineum. — Although the term Perineum should in strictness 
6 



82 GENITALIA. 

apply to the whole of the space between the point of the coccyx and 
the lower end of the genital fissure, it is commonly, in midwifery, 
used in a more restricted sense, and indicates that space which exists 
between the lower end of the vulva and the anus. It is from an inch 
to an inch and a half in length. It is covered externally and below, 
with a dense but elastic skin. It is limited above, by the vagina, and 
posteriorly by the rectum; for, as the vagina and rectum are united 
by what is called the recto-vaginal septum, it is evident that the 
pyramidal space existing betwixt this septum, the fourchette and the 
anus, must constitute the perineum, using the word in its common 
acceptation. 

It is, in labors, very thick in some women, and feels extremely hard 
and resisting; in others it is very thin, soft, and easily dilated. Upon 
its rigidity or its extensibility depends the amount of time which will 
be required for its dilatation by the fetal head, or other presenting 
part. 

The student ought to pay great attention to the study of the peri- 
neum. Without a clear knowledge of its nature, and of its obstetric 
functions, he cannot comprehend certain phenomena in what is called 
the mechanism of labor. As I wish to avoid anticipating the subject, 
I shall only state, in this place, that to the resistance of the perineum 
is owing the extension of the head; and that this extension happens 
because, when the vertex comes just behind the crown of the pubal 
arch, in flexion, the energy of the pains is directed to the object of 
pushing off the perineum, in order to open the body for the birth. 
Now, while the crown of the head pushes the perineum away from the 
top of the arch, the perineum by its resistance thrusts the occipital bone 
of the foetus firmly against the arch, holds it there in close contact, and 
thereby compels the vertex, as it emerges, to rise upwards, along the 
genital fissure and the mons veneris. When the extension is com- 
plete, the child's head is born. See Fig. 13. 

I have already mentioned that the anterior edge of the perineum is, 
in many women, but little below the top of the pubic arch, and that 
the vulva is not opened until after the perineum has been some- 
what pushed outwards and distended. It does sometimes happen 
that more than one-half of the foetal head escapes from the lower strait, 
carrying out the perineum along with it, while the vulva is only 
opened enough to let the apex of the head emerge a very little. 
When distended in this way, the perineum is, perhaps, not thicker 
than the scalp, or even less so ; covers the head like a cap, and instead 
of being from an inch to an inch and a half long, measures between 



GENITALIA. 83 

three and four inches. This great extension is sometimes kept up 
for a considerable length of time. 

The time necessary for the complete expansion of the perineum is 
very different in labors. I have waited six hours by the bedside 
after the head had begun to distend this part, and witnessed repeated 
efforts of the womb to overcome the resistance, the head being always 
forced back into the excavation by the elasticity of the perineum and 
the contraction of the levatores ani, until, at last, some long and 
powerful pain has forced it through the birth. It is highly import- 
ant, in making a prognosis, to have a very careful reference to the 
state of the perineum, as it alone often furnishes greater resistance, 
and consequent delay, than the os uteri, the straits and the vagina 
together. 

There are not a few cases in which it wholly refuses to dilate, and 
then, the child is forced downwards at the expense of the tissue, 
which bursts or is rent asunder, allowing of the immediate egress of 
the head. 

This laceration of the perineum generally takes place when the 
vulva is largely distended, the rupture commencing near the four- 
chette, and extending backwards as far as the anus, or even into the 
rectum. In other instances, the child has been expelled through a 
laceration of the perineum proper, not including the fourchette or any 
part of the vulva, the perforation being made betwixt the anus and 
vulva; the vagina is, of course, torn open. 

When such accidents happen without involving the bowel or its 
sphincter muscle, no very bad consequences are apt to ensue, the 
parts readily healing, by the continued and close contact of the sur- 
faces, with granulation. 

Should very hard and extensive cicatrices be formed in conse- 
quence of such lacerations, the vagina and perineum maybe rendered 
less fitted for the distensions of a subsequent labor, in which great 
care ought to be taken to obviate the repetition of so very untoward 
an accident. 

Lacerations do not always commence at the fourchette. I have 
already mentioned cases in which the lower third of the right labium 
was broken off, and an irregular lacerated wound extended from that 
point towards the perineum. The accident cannot be always avoided, 
even by the greatest care and skill. I have recently seen a case of 
laceration, in which the wound, commencing very near and within 
the inner third part of the left nympha, extended downwards and 
backwards, and then upwards in the vagina, in such a manner as to 



84 THE VAGINA. 

have cut the tube nearly half off— a very singular case, and which 
must have been near allowing the head to come through the perineum. 
In all instances where the power that urges the child forth is very great, 
there is risk that the infant may be expelled before the perineum and 
vulva have sufficient time to dilate : they are, therefore, apt to be 
ruptured. Lacerations sometimes take place in forceps operations ; 
probably from want of patience in waiting for the dilatation of the 
parts, time not being allowed for the yielding of the textures. It is the 
invariable duty of the accoucheur to see that the parts shall have time 
to relax and dilate before the head is permitted to emerge ; an end 
which he can generally compass by supporting the perineum ; making 
pressure against it so far as he may dare, aiding it to jam the occi- 
pital region closely against the crown of the arch, and thus, while 
the head is kept from advancing, permitting the tissues to acquire the 
proper temper or disposition to yield. This, however, will be more 
apropos when we come to treat of the management of labor. 

The Vagina. — The Vagina is a membranous tube that connects 
the external with the internal organs of generation. Its length varies 
in different adult persons, being commonly longer in virgins than in 
women who have borne children recently, and especially in such as 
have given birth to a numerous offspring. It is also longer in preg- 
nant women about the fourth or fifth month, in consequence of the 
rising upwards of the gravid uterus, which then rests on the brim of 
the pelvis. A portion of its upper and posterior part is attached to 
the rectum by the recto-vaginal septum, and it is united to the urethra 
by the vesico-vaginal septum ; near its lower end it is provided with a 
sphincter muscle that serves to close it with more or less force. 

Occupying the middle of the pelvis, where the transverse diameter 
is more than four inches long, the sides of the vagina, when distended 
so as to receive the foetal head, may be carried laterally as far as the 
planes of the ischia. A great distending force is often required for this 
purpose, and the practitioner is detained for hours in order to obtain 
the requisite dilatation of the vagina. Such resistance depends upon the 
unyielding nature of its own proper tissue, and not upon any obstinate 
opposition from the surrounding textures : there is nothing betwixt it 
and the ischia, except the levatores muscles and a very loose cellular 
tela, comprehended betwixt the folds of the ligamenta lata. 

The lower end of the womb is attached to the upper extremity of 
the vagina. If the vagina becomes shortened and its two extremities 



THE VAGINA. 85 

approach each other, the womb sinks lower down into the pelvis than 
its natural level. If the vagina be subsequently elongated by any 
means, the womb is carried upwards again. A prolapsion of the 
womb is essentially a shortening of the vagina, and the cure of such 
prolapsion is to be effected by restoring to this canal its proper lon- 
gitudinal dimension. A prolapsion of the womb is never a disease 
of the womb itself, but of the vagina and other parts that support the 
organ. 

It seems to me to be almost a work of supererogation to make this 
assertion — and yet I am led to do so because so much is said of the 
ligaments that suspend the womb. 

Let the student remember that there is a complete peritoneal cul- 
de-sac betwixt the rectum and the vagina. This is the cul-de-sac 
into which the fundus uteri falls in cases of total retroversion. It 
is clear then that here at least there is no suspensory ligament of the 
womb. The ligamenta lata do not suspend it — they merely stay it 
laterally, while the ligamenta rotunda serve to retain it in normal pro- 
pinquity to the pubis — or to keep it from oversetting backwards 
when a full bladder of urine tends to turn it over, or retrovert it. The 
anterior wall of the vagina, and parts of the womb itself, are con- 
nected with the bas-fond of the bladder. 

Such are the means of suspension of this organ within the pelvis. 
Is it not manifest that an elongated vagina carries the womb upwards, 
while a shortened or relaxed one lets it fall down, and that prolapsus 
is a fault of the vagina, which in procidentia becomes actually 
inverted, and comes quite forth from the genital fissure ? 

While in Bartholomew's Hospital at London in 1845, Mr. Edward 
Stanley showed me a case of procidentia uteri, in which the tissues 
of the vagina had become so enormously thickened — the womb, doubt- 
less, also much engorged — that that able surgeon in vain endeavored, 
for a long time in my presence, to return the mass into the cavity of 
the pelvis. The woman was in much pain. The accident had hap- 
pened several days before I saw the case. Mr. Lawrence was 
requested by Mr. Stanley to endeavor to replace the tumor — which 
he effected after considerable effort. 

Figure 40 represents very well the appearance of a case which 
I was invited to attend with Dr. Hains of this city. The woman 
was about seven and a half months gone with child. There pro- 
jected through the genitalia, a tumor as large as a man's arm and 
near five inches in length, covered with a dry epithelium. It was 



THE VAGINA. 




rugous as in the drawing. At the lower end or point was a deep 

pit. Upon thrusting the finger upwards to 
the metacarpus, in this cylindrical canal, 
the os uteri of the gravid womb was felt 
on a level with the rami of the pubis. I 
returned the whole mass within the pelvis, 
but it came down again. It consisted of 
a thickened and inverted vagina. It was 
thickened by infiltration. A pessary w T as 
adjusted, but the woman would not w T ear 
it. At full term she gave birth, in an easy 
labor, to a healthy child. At the beginning 
of the labor it was down. The labor pains 
had hardly set in, before the whole mass 
retired within the ostium vagina, as I was 
informed by Dr. Hains, who attended her 
in the confinement. 
The internal lining of the vagina is a mucous membrane, abundantly 
furnished with mucous follicles, whose secretions lubricate the parts 
in health, and particularly during labor, when their presence is of the 
greatest consequence. The parts, when deprived of it by frequent 
examinations, become dry and inflamed, which prevents their yielding 
to the distending forces, whereby the patient suffers protracted dis- 
tress that might be easily avoided by abstaining from the Touch, and 
thus preserving the humid and soft condition of the organ. Too fre- 
quent Touching not only removes the lubrication, but irritates the 
mucous membrane : it is greatly to be deprecated, as not only useless, 
but injurious as well as indelicate. A woman in labor should be 
examined as seldom as possible. 

There seems to be a dissidence in the opinions of authors relative 
to the structure of the vagina, particularly that of its tunica propria, 
which is either a real fibrous tissue, or a mere condensed laminated 
cellular membrane. It is surely not muscular beyond the possession 
of a muscular sphincter that closes its lower extremity, and possesses 
no other contractility than that which is called elastic, and which is 
common to the whole of the cellular structure. It closes speedily 
after the passage of a child, even one of a very large size. In some 
instances, where the child's head has lingered long in the vagina, an 
hour or more elapses before its calibre becomes much contracted. For 
some hours after the birth of a child, the introduction of the hand into 
the vagina may be effected with the use of very little force. The 



THE UTERUS. 



87 



vagina is subject to eversion, or to complete inversion, where there 
is procidentia or inversio uteri. Of course such accidents can never 
occur, nor can any tendency to them take place, without deranging 
both the bladder and rectum in consequence of their textural con- 
nection with this organ. 

The Womb. — The Uterus is attached to the upper end of the vagina. 
It is a pear-shaped body, compressed from front to rear, and varies in 
length, which may be from two and a half to three inches, being larger 
in women who have borne children than in those who have never been 
impregnated. It is divided into fundus, body, and neck ; the fundus 
being the uppermost, and the neck the lowermost part of the organ. 
The vagina is united to the womb in such a way as to permit its neck to 
project a short distance into that tube; in this regard also there is great 
variety, some women having almost half an inch of the cervix uteri 
hanging down in the vagina, while in others the connection seems to 
exist almost at the lower end of the cervix. See the engraving. 

The cut represents the womb 
b, and the vagina h, laid open, Fig. 41. 

in order to show the neck and 
mouth of the w T omb b project- 
ing into the upper end of the 
vagina. In it are also seen the 
round ligaments g g; the ova- 
ries e e; the ligament of the 
right ovary f, and the Fallopian 
tubes c c, with their fimbriated 
extremities d d. 

As the vagina is a curved 
canal, which proceeds back- 
wards from the vulva, and up- 
wards towards the rectum, it 

happens that the womb lies rather nearer to the sacrum than to the 
pubis. The womb is so situated that its long diameter is parallel to 
the axis of the superior strait, while the vagina is nearly parallel 
to that of the inferior strait ; hence, at their junction, they make an 
obtuse angle, any deviation from which implies a displacement of the 
womb. 

The breadth of the womb is about an inch and a half; its thickness 
about one inch. I subjoin a drawing that represents the internal or- 
gans divided transversely from top to bottom, and showing the front 




K8 THE UTERUS. 

or anterior half: a is the fundus or bottom of the womb, which is the 

Fig. 42. 




uppermost or highest portion of the organ, b is the triangular cavity, 
whose outlet is through the canal of the cervix (c), leading down to 
the orifice of the womb in the vagina, which orifice is called os 
tincse, or os uteri. At d d are seen the left and right Fallopian tubes 
laid open, to expose the narrow passage by which the ova are con- 
ducted from the ovaria f f. e e are the fimbriated extremities of the 
tubes, which are also called morsus Diaboli, or Devil's-bit. They 
are the infundibula which take up the ova as they spontaneously 
escape from the surfaces of the ovaries, which expel them once a 
month. The wing-like expansion on each side of the womb is a 
broad ligament, and the round ligament is seen through it and in 
front of it on either side of the uterus. 

Suppose half an inch of the cervix uteri to project into the upper 
part of the vagina; then, if the whole length be three inches, we 
shall have two and a half inches of the w T omb above the upper end of 
that canal. Such being the case, the w 7 omb w r ould fall over to the 
right or left side of the pelvis, were it not restrained or stayed by what 
are called its broad ligaments, which, passing from its sides towards 
the sides of the pelvis, keep it steady, or prevent it from assuming 
an oblique attitude; it would also fall backwards towards the sacrum, 
and sometimes become lodged or wedged under the promontory of 
that bone, were it not restrained from moving in that direction both 
by its round ligaments and by its connections with the bladder. It 
cannot fall forwards, for it is sustained by the bas-fond of the blad- 
der, which, by filling with urine, must, and does always push it 
backwards again. 

Structure and Powers of the Womb. — The substance of which 
the womb is composed has not been fully understood. In the unim- 
pregnated state, it is dense and gristly to the feel, and cuts very hard ; 



THE UTERUS. 89 

the cut surface being of a faint pinkish hue,and of a fibrous appear- 
ance ; but those fibres are disposed without any apparent regularity 
or order. It is supplied with blood-vessels, absorbents and nerves, 
which are very small during the unirapregnated state; but the same 
vessels in the gravid womb acquire an enormous size, and are exceed- 
ingly numerous and tortuous, so that, in fact, the ovum, at full term, 
appears to be contained within a vast net-work, or rete vasculosum, 
united together by a quantity of muscular fibres. The womb, at the 
full term, is an exceedingly sanguine organ, being furnished with 
torrents of blood from the uterine and spermatic arteries, the former 
reaching it from below, and the latter from above, with free inoscula- 
tion of the several channels of circulation. 

As to the interior membrane, or mucous coat of the womb, it is 
unnecessary to speak here : the cut, exhibiting Mr. Coste's view, will 
explain the matter with sufficient clearness. 

Various attempts have been made to demonstrate the muscular fibres 
of the womb, and they have been divided into layers and planes and 
fasciculi for that purpose ; but the very fact of such difference of 
opinion is proof enough that the arrangement of them is not yet 
clearly known. If it were known and demonstrable, there would no 
longer exist any dissidence concerning it, since whatever is clearly 
demonstrable, ceases to be a subject of dispute or doubt. This much, 
at least, is well known; namely, that the contractile fibres of the 
womb are capable of acting partially, or so as to change the form of 
one part of the organ, while another part of it acts w T ith less intensity, 
or not at all. Thus, it occasionally happens that we find the uterus, 
after delivery, contracted in its middle, as if a string had been passed 
round it and drawn tightly, causing it to assume the shape of the 
hour-glass. This state is familiarly denominated an hour-glass con- 
traction. Again, we not unfrequently find the whole organ elongated, 
and almost of a farciminal form ; its fundus being raised high upwards, 
towards the epigastrium, while the body of it is narrow or slender like 
an intestine. I feel assured that I have sometimes found it, after de- 
livery, full nine or ten inches in length, and not more than four inches 
in transverse diameter, estimated by feeling it through the relaxed in- 
teguments of the abdomen. These circumstances prove that the ute- 
rine fibres which affect the conjugate diameter of the organ may act 
with force, while those which affect its longitudinal diameter are either 
in a state of repose, or of very slight action ; which leads us, as I 
think, to the inference, that the longitudinal and horizontal fibres are 



90 



THE UTERUS. 



Fig. 43. 




separate and independent organs or parts of the uterine structure. 
The annexed cut from M. Chailly's 
Midwifery, gives a view of the ar- 
rangement of muscular fibres which 
seem to converge upon the tubes and 
round ligaments. Let the student 
conceive of a separate non-coordi- 
nate action in these fascicles of mus- 
cles, and he will perceive that such 
action might greatly embarrass a la- 
bor in which the contraction ought to 
be consentaneous for the whole mus- 
cular apparatus of the organ. 

If this be a just view of the case, 
it will serve for the explanation of 

occurrences in labor that would otherwise embarrass us not a little; for 
example, we find the woman in travail sometimes suffering under the 
most intense pains, and making the greatest efforts without the smallest 
profit; and that, too, where we know certainly that the pelvis is of 
the amplest dimensions. What can be the cause that the child does 
not advance under such vigorous efforts? We find that the head is 
positively stationary notwithstanding the healthiest pelvic conforma- 
tion, a sufficient dilatation of the uterus, and violent labor pains. We 
are at once satisfied, and relieved of anxious doubts, when we reflect 
that the horizontal or transverse fibres are acting, and the longitudinal 
or perpendicular fibres are inert. There is a failure of co-ordination 
in the movements, and our duty will be clearly seen to consist in 
endeavors to restore the symmetry of contractile effort. 

As this circumstance generally results from some excess of a local 
or constitutional irritation, the former occasioned by tedious or violent 
labor, rheumatism, officious intermeddling, or the direct stimulation 
of ergotism ; and the latter by a too susceptible nervous system, re?- 
pletion, mental emotions, or vain efforts of labor long continued : it 
appears that, in the former case, we ought to resort to the tranquiliz- 
ing influences of laudanum clysters, cool air and drinks, and absti- 
nence from impertinent handlings ; whereas, in the latter, we may 
apply to the lancet, to a Dover's powder, to portions of morphia, or 
the black drop or opium, or the bath, after evacuations have been 
procured from the bowels by emollient and laxative injections; and 
that w T e ought to give orders for a full and free ventilation, and the 
use of suitable drinks. 



THE UTERUS. 91 

But if it does sometimes happen that the movement of the hori- 
zontal fibres is inordinate, or in excess, it fortunately happens in the 
vast majority of cases that the powers of the longitudinal fibres are 
the greatest. The ovum being contained entirely within the uterus, 
it appears that it can only be expelled by the fundus approaching the 
os uteri ; or, in other words, by the shortening of the womb that 
results from the contraction of its longitudinal fibres. Let us remem- 
ber that the womb is attached to the upper end of the vagina, and that 
the ovum, in passing out from the uterus, must necessarily traverse 
that canal. It will then appear that the first contraction of the longi- 
tudinal fibres will tend to pull the circle of the os uteri open at the 
same time that the point of the ovum is insinuated into the enlarging 
orifice. This opening or dilatation of the orifice does not take place 
without resistance, which is chiefly perceptible, however, in the early 
stages ; for we find that while the fundus and body of the womb are 
vigorously condensed during a pain, the cervix also is strongly con- 
tracted, but less and less vigorously, as the dilatation becomes more 
considerable ; so that, indeed, it is not rare, at length, to perceive 
the whole circle of the cervix yield as if without opposition, to the 
greater power of the longitudinal fibres. The circle of. the os uteri 
is as it were pulled upwards, towards the fundus uteri, by the mus- 
cular expulsive powers ; so that it seems to be stripped over the lower 
segment of the ovum, over the head, or over whatsoever presenting 
part. I have known the whole dilatation to take place during a 
natural sleep. 

Some women require only a few pains to complete the dilatation, 
whereas others suffer hundreds of pains during several successive 
days, before the circular fibres are conquered by the protracted efforts 
of their antagonists. 

From thirty-five to fifty pains are probably felt by the average 
number of parturient women. If four hours be a mean of the dura- 
tion of labor, then the woman will be likely to have pains at the rate 
of one every ten minutes for the first hour — which would be six 
pains. She would probably have ten pains in the second hour, fif- 
teen in the third hour, and twenty pains in the fourth and last hour of 
the process — say, in all, fifty pains. 

While the generality of cases are thus favorable, there are multi- 
tudes of women who have not more than three or four; whereas some 
of them suffer from the repetition of two hundred contractions, and 
even a greater number than that. 

A considerable experience and trained habits of observation are 



92 THE UTERUS. 

necessary to enable a practitioner to prognosticate the moment of de- 
livery, making up his judgment from the intensity of the pains of 
expulsion, as compared with those of opposition or retention. It is 
certain that no man, be his experience ever so great or his discrimi- 
nation ever so acute, can with absolute certainty calculate upon the 
moment when any given labor shall be brought to a conclusion, since 
no one can absolutely predict what shall be the exact degree of in- 
tensity of any muscular force, which, as it is a vital operation, so it 
is dependent on causes beyond our foreknowledge or perfect control. 
Young and inexperienced practitioners ought, therefore, to be very 
late in announcing their prognostic of the end of labor, as to time. 

I have remarked, that as the longitudinal fibres pull the os uteri 
open, the apex of the ovum is inserted into the opening : with each 
succeeding pain additional portions of the ovum pass into the os uteri, 
and through it, until at last, the fundus having approached very near 
the cervix, the whole of the ovum becomes excluded from the uterine 
cavity, after which the same longitudinal and horizontal fibres, meet- 
ing with no further considerable resistance, act in concert, and thereby 
reduce the womb down to -a very small size. It returns but slowly 
to the non-gravid condition. From fifteen to thirty days are required 
to effect this reduction. Let it be remembered that the womb is 
capable of contracting equally upon an ovum at term, and upon an 
abortion of three weeks, 



THE OVARIES. 93 



CHAPTER V. 



THE OVARIES. 



The ovaries are organs for the preparation of ova, or eggs, which 
contain the germ of the offspring. 

In the mammals there are two ovaries, within each of which may 
be seen, with a good lens, from twelve to fifteen eggs, or yelks, in- 
closed within their proper capsules or ovisacs, which are commonly 
called Graafian follicles, or ovarian follicles. They were some time 
since denominated Graafian ova — because de Graaf imagined that 
these pellucid bullae w T ere the ova of the animals in which they were 
seen by him. Let the Student early make the discrimination between 
the follicle, the cell, or ovisac which contains the egg, and the minute 
egg itself, which is too small to be readily seen by the naked eye. 

The human ovary is about an inch in length, half an inch in depth, 
and more than a quarter of an inch through; in shape it is like a com- 
pressed olive. 

Each ovary is attached to the angle of the womb — one on the right, 
and the other on the left corner. It is connected with the uterus by a 
short foot-stalk of a fibrous structure, which is called the ligament 
of the ovary. 

The ovaries lie behind the Fallopian tubes, enclosed in a duplica- 
ture of the peritoneum, which adheres firmly to the proper covering 
or coat of the organ ; so that the ovary is invested by a serous mem- 
brane, as the liver, stomach or intestines are. 

Underneath the serous covering lies the strong white fibrous coat, 
or tunica albuginea, which is a closed sac containing the stroma, 
the peculiar tissue of the organ. There is thus no proper excretory- 
duct for this organ ; nevertheless, the Fallopian tube becomes, upon 
occasions, the vector of its product. The connection of the vector tube 
with the organ exists, in all probability, only during the moments of 
the sexual excitement, or orgasm. In the embryo, as late as to the 
sixth month, the end of the Fallopian tube is permanently attached 



94 THE OVARIES. 

to the ovarium — before the seventh month the connection is broken. 
See Rosenmuller, Qucedam de Ovaritis Embryonum et Fcetuum Hu- 
manomniy p. 11. 

I have a specimen of foetus at the sixth month, in which the de- 
tachment has not taken place. 

The stroma of the ovary, with which the closed sac of the albu- 
ginea is filled, is a peculiar concrete, consisting, apparently, of a 
rather dense cellular tela, which is salmon-colored. Throughout the 
stroma are to be seen numerous delicate arterioles and venules, that 
are the distal branches of the spermatic artery, or, perhaps, more 
properly speaking, the ovaric artery. It is worthy of observation, 
that the blood of this circulation is brought from a great distance, 
since the ovaric artery arises on one side from the emulgent, and on 
the other from the aorta itself. As the ovaries, like the testicles in 
the male, are originally formed high up in the abdomen, near the 
kidneys, an economical purpose was answered by deriving their cir- 
culation from these sources. Whether there be any further and pe- 
culiar economical end to be attained by drawing this blood from such 
a distant point, remains unexplained. 

If the tunica albuginea of an ovary be divided with a scalpel, the 
stroma may be readily torn asunder by pulling the edges of the inci- 
sion apart with the fingers. 

The ovary of a mammal, when examined for the purpose, exhibits 
several watery vesicles, whose translucency renders them visible 
through the indusia or coats of the organ. By cutting the ovary 
open, and by carefully dissecting them out, these vesicles or bullae 
may be completely freed from all attachment, when they appear as 
globules filled with water, and of sizes varying from the bigness of a 
garden pea to that of a small bird-shot. In each ovary may be 
counted some fifteen of these vesicles. 

These Graafian vesicles — for so they are usually denominated — are 
also called Graafian follicles, Graafian cells, Graafian ova, and ovarian 
follicles. They are ovisacs. They are composed of a double mem- 
brane, one inside of the other. 

If a Graafian vesicle be punctured with a lancet, there spirts out, 
through the cut, a drop of water. This drop of water, when col- 
lected on a glass, or knife-blade, and placed under the microscope, 
is found to consist of a pellucid liquor, in which swim a great number 
of small grains. Among these grains there is a portion in which the 
grains are agglomerated in greater number, and in the midst of them, 
a yelk-ball is found. 




THE OVARIES. 95 

Figure 44 represents this yelk-ball, bounded by a white, transpa- 
rent zone, which is called its zona pel- 
lucida. It is a perfect sphere, filled Fi s- 44 - 

with vitellary corpuscles, oil globules 
and puncta that swim in a transpa- 
rent liquor. The sphere or yelk-ball 
lies amidst the granules of the tunica 
granulosa before mentioned, as may be 
seen in the figure, taken from Rudolph 
Wagner's Prodromus. 

Outside of, or beyond the white zone, 
or zona pellucida, are the smaller gra- 
nules of the tunica granulosa, so that the ovum above represented is 
bounded by the transparent or white zone. These outside granules 
are the remains of the granular membrane that lines the inner 
concentric membrane of the Graafian follicle. 

Perhaps the physiologists go too far in calling it a membrane. 
— It consists of innumerable grains that settle themselves, touching 
each other, upon the inner wall of the vesicle, like the sediment in 
a vial. I do not deny that they deposit themselves thus under 
the forces of a vital affinity, and it is even probable that they do so — 
but whenever this vesicle is punctured, this so-called membrane be- 
comes decomposed, and floats out as grains along with the yelk-ball, 
great imiltitudes of them adhering to it. 

This granular membrane, or tunica granulosa, is thickest, in gene- 
ral, at that segment of the Graafian vesicle which is nearest the sur- 
face of the albuginea, and it forms a small heap — an acervulus or 
cumulus, which has been by Baer called the cumulus proligerus or 
discus proligerus. It is in the apex of this cumulus or cone that the 
egg is found, and it is chiefly among the debris of this acervulus that 
the microscope reveals the yelk, with its bright pellucid zone. 

Upon referring again to the above figure, the student will see, that 
in the yelk-ball, amidst its vitellary corpuscles, there is pictured a 
clear, transparent, oval vesicle, with a dark spot upon it. This is the 
germinal vesicle, and the dark spot is the germinal spot, or 
macula germinativa, which M. Coste calls the tache embryonaire. 

Such, in general terms, is the human ovary, which, I repeat, con- 
sists of a closed sac, filled with ovarian stroma, in which are deve- 
loped ova within capsules called Graafian follicles. These ova are 
true yelks about one-fifteenth of a line in diameter; in each unfecun- 
dated yelk is a germinal vesicle one-sixtieth of a Paris line in diame- 



96 THE OVARIES. 

ter, and having upon its inner surface a germinal spot consisting of 
dark granules — the germinal spot being one-two-hundredth or one- 
three-hundredth of a line in diameter. 

I have many times observed the numerous granules, or dark puncta, 
that may be inspected by placing thin slices of ovary on the field of 
the microscope. There are immense numbers of these points, which 
are, by some, supposed to be nuclei, or cytoblasts — the inchoate ele- 
ments of ovarian ova. Such is the opinion of Martin Barry, who 
gives, in his papers, published in the London Phil. Trans., drawings 
of these appearances in the ova of various animals. 

If this notion be indeed founded in truth, then each ovary should 
be held to contain, not fifteen ova only, but the nuclei of hundreds of 
thousands of them. 

Perhaps, however, the microscopic view is not correct, and these 
points are acini of the gland, if it be a gland. Supposing them 
to be acini, and that an acinus may, by some physiological act, be 
cast off from its connection with the stroma that produced it, and 
carry away with it, like an inoculated bud or like a spore, or a pol- 
len grain, the metabolic and the plastic forces — by which to develop 
the ovarian ovule — still we have, in either case, the idea of a pro- 
ductiveness in creatures beyond imagination for vastness. 

The ovaries are abundantly supplied with nerves, derived (Longet, 
t. ii. 543) from three or four branches that come off from the renal 
plexus, and proceed, in company with the ovaric artery, to the place 
of distribution. They are called the ovaric plexus, and spend their 
terminal fibrils within the ovary, and in part, also, within the uterus, 
thus connecting the two organs in a common bond of sympathies. 

Regner de Graaf, of Delft, in Holland, where he died at the age of 
thirty-two years, on the 17th of August, 1673, published his work 
De Mulierum Organis Generationi Inservientibus in 1672, and gave, 
as I have said, his name to the ovarian vesicles, or ovi-capsules. 
They were by him considered to be ova, and were long, and even 
until lately, by many, regarded as ova, for no one, until recently, had 
acquired any correct notions of the ovum of the mammiferse. 

It is a title to immortality in the Republic of Letters, to have dis- 
covered the ovum of the mammal, and there has been a great conten- 
tion as to the priority in this claim. It appears to me that, although 
one person may have first seen the object, so many individuals have 
been concerned in establishing and explaining the natural history and 
physiology of the fact by laborious researches and patient efforts of rea- 
son, that no single person should be deemed entitled to all the credit; and 



THE OVARIES. 



97 



it is certain, that the world is too much indebted to divers persons on 
this account, not to divide the honors of the career among many claim- 
ants. I feel no inclination to enter the lists of this controversy in favor 
of any particular person, in which I have no other than a common 
interest of gratitude to the ingenious philosophers who have illumined 
my therapeutical path with floods of radiant light, freeing me from the 
errors and gropings of my blind predecessors, and enabling me clearly 
to perceive, and plainly understand, many mysteries of physiology and 
therapeutics that were utterly hid from their eyes. 

But the student of medicine ought to be somewhat acquainted with 
the literary history of the subject, lest he wander among authorities 
that have now ceased to have any claim to his obedience. Let him, 
therefore, understand that a meeting was held at Breslau, in Silesia, 
in the year 1825, in honor of the fiftieth year of the Doctorate of 
Professor Blumenbach. At that meeting was presented a volume 
under the following title: — Joan. Fried. Blumenbachio, etc. Sum- 
morum in Medicina honorum semis cecularia gratulatur ordo medicorum 
Vratislaventium, interprete Joanne Ev. Purkinje. P. P. 0. Sub- 
jects sunt symbolce ad ovi avium kistonam ante incubationem : cum 
duobus lithogr aphis. Vratislavice, Typis Universitatis. This volume 
was printed in September, 1825, and was not published, being de- 
signed only for private distribution. An edition of it was published for 
sale at Leipsic, in 1830, 4to., of which a copy is now before me. 1 look 
upon Professor Purkinje's book as the first in the series of the works 
of reform as to our knowledge of the ovaria. This is the work in 
which was first made known the existence of the germinal vesicle, 
commonly called the Purkinjean vesicle, of the bird's egg. 

Professor Purkinje had interested himself in the investigation of the 
cicatricula, or tread of the hen's egg. He was examining it in a 
vessel of water, in order to learn the nature of the cumulus that 
lies directly underneath the cicatricula, and of which Figure 45 is a 



Fig. 45. 



Fig. 46. 





representation. It has been very beautifully produced on wood by 
Mr. Gihon, from the original lithograph. 
7 




98 THE OVARIES. 

While, with a pair of dissecting needles, tearing the yelk asunder 
under water, and removing the broken-down masses with a pipette, he 
came upon a "most beautiful vesicle, " partly adhering to the 
margin of the pore in the apex of the cumulus, and partly detached 
from its bed therein. His own words are — "Haec dum lente ope 
perlustro, vesicula formosissima parte margini pori adherens, parte 
libera haud parum mirabundo mihi offertur." P. 2. Figure 47 ex- 
hibits this appearance. 

The cavity in which this Purkinjean, or germinal vesicle (the first 

that was ever seen), is contained, is 

Fi<* 47 . . 

represented by Purkinje as in the an- 
nexed cut, Fig. 47, also copied from 
his lithograph. It is a cross section 
of a portion of the yelk-ball and the 
cumulus, with its cavity, in the hol- 
low of which was found the Purkinjean vesicle. The transparent 
vesicle thus revealed, is almost as delicate in its structure as a soap- 
bubble. It can be found only in eggs that have not been fecundated, 
such as the pullet's egg, or yelks taken out of the ovary, in which, 
according to Von Baer, it exists, even in the very smallest yelks. 

The student now has a clear understanding as to the germinal or 
Purkinjean vesicle, discovered and made known in September, 1825. 

The next publication in the order of important discovery, w T as the 
De ovi Mammalium et Hominis Genesi. Epistolam ad Academiam 
Imperialem scientiarum Petropolitanam, dedit Carolus Ernestus A. 
Baer. Zoologies Prof. Publ. ord. Regiomontanus, cum Tabula Aenea. 
Lips. 1827, 4to. 

Such is the title of Von Baer's letter to the Imperial Academy of 
Sciences at St. Petersburg, on the subject of the ovum of the mam- 
miferous quadrupeds. 

In Von Baer's experiments, he, like Purkinje, never could find the 
vesicle in eggs already laid, but always detected it in even the small- 
est yelks of the egg bag. He supposes it to be the nucleus around 
which the matter of the yelk becomes subsequently aggregated. — 
This was the case also in the molluscs, in the lumbricus and in the 
leech. These researches led him to the discovery of the mammife- 
rous ovulum, in the following manner. 

Having observed a very minute ovulum in the Fallopian tube of 
the bitch, and feeling that such small ova could not consist of Graaf- 
ian vesicles, which are much larger, and that the liquor of the vesicle 
could not so soon acquire the firmness and solidity of the tubal speci- 



THE OVARIES. 99 

men, he was led by curiosity, rather than by the hope of seeing with 
the naked eye, through the several coats of the Graafian vesicles, any 
ovula in the ovaries, to open a follicle with his scalpel, and placing 
the fluid that came forth upon the platine of his microscope : " Ob- 
stupui," says he, " profecto, cum ovulum ex tubis jam cognitum tarn 
clare viderem, ut ccecus vix negaret. Mirum sane et inexpectatum, 
rem tarn pertinacitur quaesitam, ad nauseam usque in quocunque 
compendio physiologico uti inextricabilem tractatam, tarn facillimo 
negotio ante oculos poni posse." P. 12. He informs us that this 
ovulum may, in some specimens of the ovary, be seen through the 
coats of the ovi-capsule. 

Everybody seems willing to concede to Von Baer the honor of this 
discovery, which was effected two years later than that of Purkinje, 
viz., in 1827. But, notwithstanding his good fortune as the disco- 
verer, he is not the true expositor of its nature, for he mistook the 
ovulum or yelk for the Purkinjean vesicle, and he says — " Demonstrabo 
enim mammalium ova vesiculis Purkinji reliquorum animalium com- 
parandas esse, quas in animalibus nonnullis, molluscis, acepalis v. c. 
et lumbricis ovorum evolutionem antecedere clare me vidisse puto" — 
that is to say, " he will show that the mammal ovum is to be com- 
pared with the Purkinjean vesicle in other animals, and that the evo- 
lution of it precedes that of the ova in certain molluscous creatures, 
as he' supposes to be verified by his observations." 

At p. 32, he argues the identity of the nature of the Graafian ova, 
and the ova of birds and spiders, which have a great quantity of vi- 
telline capsules and but little liquid, while the Graafian ova bear but 
few corpuscles and much albuminous fluid. " Besides, they resemble 
eggs in possessing a vesicle situated in a cumulus, and surrounded 
with a proligerous layer. Therefore, a Graafian vesicle, in view of 
the ovary, and in general, of the maternal constitution, is the true 
ovum of the mammal. 'Vesicula ergo Graafiana cum ad ovarium 
generatimque ad corpus maternum respiciamus, ovum sane est mam- 
malium.' ' Von Baer, notwithstanding the tyranny of the schools, al- 
most saw the real truth, for he remarks upon the fact, that the whole 
Graafian ovum cannot, as in birds, be transferred to the vector tube. 
" Hence in mammals," says he, " the inner vesicle (the true ovum) 
contains a richer vitellary matter, and as to the evolution of the foetus, 
it certainly proves itself to be a true ovum." In saying this, he was 
nearly free from the shackles of his scholastic prejudice. They were 
strong enough, however, to cause him to write of the ovulum, "Ovum 
fetale dici possit in ovo materno. Mammalia ergo habent ovum in 
ovo; aut si hac dicendi formula uti licet, ovum in secundapotentia." 



100 THE OVARIES. 

The student, in reading the above, will candidly admit Von Baer's 
claims, though he will perceive how checked he was by the bonds of 
an old way of thinking. After all, the egg within an egg was, in 
his eyes, the true, separate, independent yelk-ball of the mammal. 

The ovum of the bitch is oV n t° iVh °f a Paris line in diameter, 
according to Von Baer. 

Now, notwithstanding M. Von Baer, as by the foregoing appears, 
is the discoverer of the mammal ovum, it is not doubted that Messrs. 
Prevost and Dumas had seen it in 1825 — the year in which Purkinje 
detected the germinal vesicle. They, on two occasions, turned out 
and saw the ovulum of the Graafian ovi-capsule in the rabbit. Yet, 
the glory is Von Baer's. 

As to the history of the Purkinjean vesicle in the mammal 
ovule , it appears now to be settled that the honor of its discovery 
belongs to Professor Coste of the College of France, though several 
Germans have attributed it also to Von Baer. 

M. Coste, in his Histoire Generate et Particuliere du Developpement 
des Corps Organises, says: 

" I was at first accused of having copied M. Baer; but, inasmuch 
as the opinions I had set forth were diametrically opposed to those of 
that great physiologist, the public early did justice to a reproach so 
unfounded, and the improper criticisms of Mr. Robert Froriep were 
promptly repelled by Bernhardt himself, in his inaugural thesis, Sym- 
bols ad Ovi Histonam, p. 25. This reproach having been set aside, 
an attempt was next made to bestow upon others the credit it was 
impossible to assign to M. Von Baer. It was pretended that the dis- 
covery was made at the same time, or nearly at the same time, by M. 
Coste in France, M. Bernhardt in Germany, and Mr. T. Wharton 
Jones in England. As to M. Bernhardt, it is enough for me to refer 
to that author's preface, in which he declares that his experiments 
were instituted for the purpose of ascertaining the correctness of my 
observations. Mr. Jones's publication is later by one year than mine ; 
a statement that might suffice for the present occasion, were it not 
that that physiologist has himself fully recognized my rights as to the 
priority of discovery, in his report on Ovology in the Brit, and For. 
Med. Review, No. 32, 1843, a paper in which he lays no claim to it 
himself, but attributes it to me." 

Thus far M. Coste, whose remark as to Bernhardt's preface is 
correct, as well as his citation of Mr. Jones's paper. 

Mr. T. Wharton Jones's words are as follows : — 

" By the discovery of the germinal vesicle, in the mammiferous 



THE OVARIES. 101 

ovarian ovum, the complete analogy between the latter and the ova- 
rian ovum of the bird, &c, was established; and Baer's error regard- 
ing it dissipated. The correct view of the matter had been suspected 
by Purkinje, but he and Valentin had in vain searched for a germinal 
vesicle, and it was only on renewing their investigations, after the 
announcement that such a vesicle had been discovered in the rabbit's 
ovum by M. Coste, that they, Wagner and others, in Germany, were 
successful in finding it. M. Coste, therefore, as Bischoff observes, 
must, notwithstanding his very imperfect description and delineation 
of the germinal vesicle, be considered as its first discoverer." 

This, it appears to me, is enough to enable the student to see 
clearly the whole case, and I shall not further cite M. Coste, in his 
warm reclamations against M. Bischoff of Giessen. 

It is much to be regretted that, in the tranquil pursuits of letters 
and philosophy, there should arise occasions for reproach — the more, 
as so much honor always remains to be shared by the diligent mem- 
bers of the Republic. The world is very ready to acknowledge the 
services and merits of all those wise, learned, and good men, who, 
like Purkinje, Baer, Coste, Wagner, Jones, and BiscbofT, have in their 
publications endowed mankind with an impayable benefit. 

The discovery of the mammal ovum was rendered complete by 
the detection, in 1830, of the macula germinativa or germinal spot. 

It is diversely attributed to Professor Rudolph Wagner and Mr. T. 
Wharton Jones, and it may be esteemed a conceded point, that it 
was cotemporaneously observed, as it was cotemporaneously de- 
scribed, by those gentlemen in Germany and in England. 

The germinal spot is, by Wagner, in his Prodromus Histories 
Generationis Hominis atque Animalium, page 4, called primitive 
Keimschicht, and macules germinativce ; Professor Wagner, in a note, 
page 44, Part I., Elements of Physiology, says : — 

"I was myself the first to discover the germinal macula. I also 
described and figured the whole ovum in its successive stages with 
greater care and sequence than had yet been done." 

Wharton Jones says: "At one side of the germinal vesicle there is 
a small, round dark spot, discovered and described cotemporaneously 
by Rudolph Wagner and the author of this report." Brit, and For. 
Med. Review, 1843, p. 517. 

The germinal spot is from one-two-hundredth to one-three-hundredth 
of a Paris line in diameter. It consists of a collection of grains. — 
Wagner's words, Prodromus, p. 4, are: "If the germinal vesicle in 
man, and in the mammifers, be carefully examined with the micro- 



102 



THE OVARIES, 



scope, at four hundred or five hundred diameters, there will be seen, 
in one part of the vesicle, a dark, round spot." 

In this way he found it in mammals, birds, scaly amphibia, carti- 
laginous fishes, arachnoids, certain crustaceans, all molluscs, concha- 
ceans, echinoderms, medusans, and polyps. Upon a more minute 
examination, under still higher powers, there is seen a compressed 
orbicular stratum, of a lenticular shape, composed of minute mole- 
cules, closely agglutinated in form of an acervulus, &c. &c. 

This granulous germinal stratum appears to be the true living 
animal germ, existing antecedently to the act of impregnation. Hoc 
stratum granulosum germinativum, germen animale verum et vivum 
jam ante preegnationem praeformatum esse videtur. 

Having now laid before the student this account of the ovary, I 
shall annex a copy of Mr. Coste's magnified view of the ovarium 
from his grand atlas. In that superb plate the figure is ten inches in 

Fis. 48. 




its greatest diameter. Mr. Gihon has reduced it to this size. It was 
necessary to make it not more than four inches in diameter. 

Mr. Coste's intention was not merely to exhibit the shape of the 
ovary greatly magnified, but to show the internal structure of it, and the 
various progress of the ovarian ova in their ovi-capsules, during their 



THE OVARIES. 103 

maturation, and the dehiscence and discharge of the follicles. It is 
the left ovarium that is represented. The expanded fimbria p, of the 
Fallopian tube p> is seen at the lower and right extremity of the draw- 
ing. Near this angle is seen a Graafian follicle v, the dehiscence or 
rupture of which has allowed a yelk, surrounded by its proligerous 
disc or cumulus, to escape. The opening has taken place through 
the tunica albuginea and the peritoneal coat, and the ovule marked ce, 
is still resting upon the exterior surface. Just above it is seen an- 
other less mature vesicle v, and a still smaller one above that — while 
farther to the left is a very small one. The line of incision passes 
near its lower angle across a pretty large and superficial follicle, one- 
half of which is seen through the coats of the ovary, and the other 
half quite uncovered by the dissection which has laid the organ open 
to view. To the right and upwards from this point is seen an 
emptied Graafian cell v, in which e is the outer surface of the whole 
cell. At v is the point of dehiscence, through which the egg escaped. 
This Graafian cell consisted of two coats or membranes, one contained 
w r ithin the other. The broken lacinise of the double ovisac are seen 
at the upper end near the margin of dehiscence, where they are 
marked g and i. These two coats are better represented in the fol- 
licle at the upper and left extremity of the cut — in which their floating 
and distinct membranes are seen at e and at i, whereas g indicates 
the granular deposits upon the inside of the follicle, which is called 
the tunica granulosa — or granular membrane. This granular mem- 
brane is so little tenacious, that upon puncturing and compressing a 
cell, it flows out with the water, and appears upon the microscope 
as a collection of innumerable grains, that are probably cytoblasts. 
Very near the superficial segment of this ovarian ovisac is seen the 
ovulum enclosed within its proligerous cumulus. 

In order that the student may here have a more complete idea of the 
ovary, I repeat the figure of the human 
egg, taken from Rudolph Wagner's Pro- Fi s- 49 - 

dromus Histor. Generationis, in which is 
seen the pellucid ring surrounding and 
enclosing a quantity of yelk corpuscles, 
among which, near the top, rests a trans- 
parent vesicle with a dark spot upon it. 
The pellucid ring is the zona pellucida of 
the egg, outside of which is a quantity of 
granular membrane that always comes 
out of the Graafian follicle sticking to the 
zone. It is necessary to remark that this 




104 THE OVARIES. 

figure is greatly magnified, for a very strong sight is required to 
enable any one to see without a lens the egglet, whose diameter is but 
the twentieth of a Paris line. The grains inside of the pellucid zone 
are grains of yelk — or vitellary corpuscles. They are yelk, true yelk, 
like that of the bird's egg. The oval transparent vesicle within them 
is the germinal vesicle, and the dark spot upon that vesicle is the 
macula germinativa — tache embryonaire — or germinal spot. 

If the student will look upon the germinal spot as the nucleolus, 
the germinal vesicle as the nucleus, and the vitellary membrane as 
the cell, he will have an idea of a true independent cell, possessing 
the metabolic and plastic forces that can enable it to develop itself 
wherever the proper cytoblastema, or pabulum, is afforded to it for 
that purpose — i. e. in the ovary, the tube, the abdomen or the womb. 

The production within the ovary, of an ovum containing within it 
a germ possessing the power of evolution solely in the direction and 
dimensions of its own genus and species, is one of the most mysterious 
and wonderful works of God : one well fitted to overwhelm the mind 
with astonishment, and to make us feel amazed at the vastness and 
the indispensableness of those forces that are communicated by a 
Divine power to the simple and microscopic elements of the macula 
germinativa. 

Burdach, in his Physiology, t. i. 87, speaking of the tubular ovary, 
in which the materials of yelks are secreted in the cavity of the 
ovaries, in order to become ova, presumes this to be the mode in 
which ova are formed in all the insects, in most of the inferior crusta- 
ceans, in worms, and in certain mollusks. "Moreover, 5 ' says he, "there 
is not the least doubt that the substances of which the es^ is coin- 
posed, acquiring through the influence of the ovary their aptitude for 
a more elevated range of life, or already possessing it, tend partly also 
of themselves to take on a determinate form." 

Is it a new creature that is formed out of the macula germinativa: 
is a question that has often been asked; or is it a propagation and 
continuation of the old or parent substance? M. Huschke proposes 
that the ovary is an aciniferous organ, and that the germs of the off- 
spring are acini, which, under a physiological law, become decidu- 
ous, but carry away in their fall the vitality and accompanying forces 
that enable them to continue, after their separation, the career of 
Existence and Development. I do not feel myself competent to speak 
with authority upon this proposition: I shall only state, that very nu- 
merous and careful microscopic examinations of the ovarian stroma 
have not exhibited to me the evidences of the aciniferous nature of 



THE CORPUS LUTEUM. 105 

that substance, wherefore I am the more inclined to adopt the opinion 
of the cytoblast character of the germ point. 

The Corpus Luteum. — Before I conclude my remarks upon the 
ovary, I ought to say something on the subject of the corpus luteum, a 
topic that has elicited an immense amount of discussion, and which 
still remains a vexata questio. Perhaps the principal interest that 
society has in the settlement of this question is one of a medico-legal 
nature; for although inquiries in this direction, of a medico-legal 
character, have not, so far as I am aware, led to any judicial deci- 
sions, I can conceive that important rights and interests might depend 
before a tribunal upon the views to be held as to the nature and inter- 
pretation of that singular product. 

The corpus luteum or yellow body is a peculiar substance found in 
the ovaries of animals that have lately passed through the rutting 
season, and in women that have lately been affected with their men- 
strua, or that have become pregnant. In some pregnant women the 
corpus luteum is either very small, 
or not readily discernible. In others lg " 

it attains a large size. In the cow, J0^^^\ 

the corpus luteum (vide Fig. 50) is /^^K()Y\m^k 

sometimes half as large as the ovary, iffy; ^wyMw^X 

Kill ( '//''•' ■ "?> n^™— ~^_ 

It has been regarded as a sure sign ^f|jjjV/'^^ ; ;:::V'',V. ■'■"'•XU^Mji^^-^ 

of fecundation. I regard it as a sign ^JlBlM ^ l) })Jljlil 0'^^ 

of a finished ovulation. 

On the 18th December, 1846, I made to the American Philosophi- 
cal Society a verbal communication, setting forth certain views I had 
entertained as to the vitellary nature of the corpus luteum ; and on 
the 15th January I read a memoir upon the subject, which was pub- 
lished in the Transactions, 1847, p. 131. In that communication 
I stated that, since the date of my first verbal memoir, I had carefully 
made researches both with my Chevallier's microscope and by other 
methods, as to the comparative appearances of vitellary matter taken 
from the egg, and matter procured from fresh corpora lutea. 

These renewed researches leave me very fully convinced that the 
yelk of eggs and the yellow matter found in a corpus luteum, are of 
the same apparent structure, form, color, odor, coagulability, and re- 
fractive power. 

Having placed a small quantity of yelk on the platine, and just 
before I had brought the object into the focus, I have been struck 



106 THE CORPUS LUTEUM. 

with the appearance of the transmitted light; a bright-yellow, which 
fills the whole tube of the instrument. 

When I have, in like manner, placed a bit of fresh corpus luteum, 
of the cow or sheep, on the compressor, and have crushed it, by- 
turning the screw, I have found the tube filled with the same tinted 
light, before obtaining the focus. 

A portion of yelk placed beneath the objective, exhibits numerous 
granules, corpuscles containing a yellow fluid, and oil-globules, mixed 
with a quantity of punctiform bodies. 

Upon turning the screw of the compressor on a small lump of cor- 
pus luteum, carefully dissected out from its indusium, there is seen to 
escape from the crushed mass a quantity of granules, corpuscles filled 
with yellow fluid, oil-globules, and punctiform bodies swimming in a 
pellucid liquor. 

The appearances observed upon examining a portion of yelk and 
a portion of corpus luteum, are so similar that it would be difficult, I 
think, to discriminate between them, but for the exception, that along 
with the vitellary corpuscles and granules and globules of the yellow 
body, there will be found floes of laminated cellular tela, blood-discs, 
and other detritus of the organ, destroyed by the compressor. 

The transparent corpuscles transmit a yellow light, whether ob- 
served singly, or in clusters, or acervuli. 

The same is true of the corpuscles of the yelk. 

On crushing a bit of corpus luteum with the compressorium, there 
escapes much granular matter that accurately resembles the granules 
of the granular membrane, the proligerous disc or retinacula of the 
Graafian follicle. This is the case when great precaution has been 
used in procuring the bit from the outer superficies of the corpus lu- 
teum ; avoiding to take any portion that might have touched the inner 
superficies of the crypt left by the escape of the ovulum. 

The similarity in the appearance leads me to suppose an identity 
of nature and origin. 

I think no person accustomed to the use of the microscope could 
detect any difference between the molecules pressed out of a bit of 
corpus luteum, and those that escape from a crushed mammiferous 
ovule, or the yelk of an egg, excepting the debris or detritus before 
mentioned, which is plainly referable to the destructive power of the 
compressorium. 

I have so many times examined the mammiferous ovulum that I 
suppose myself quite competent to compare its contents with those 
of the corpus luteum, and with common yelk. 



THE CORPUS LUTEUM. 107 

I hope I am entitled to say, that the coloring matter and the chief 
constituent bulk of a corpus luteum, is a true vitellary 
matter, deposited outside of the inner concentric spherule, or ovisac 
of the Graafian follicle. 

For the proof of the truth of this opinion I refer to the future ob- 
servations of the micrographers, who will be able to confirm or to 
confute my statement. 

There is not, so far as I know, any author who has taken this view 
of the constitution of the corpus luteum — though that substance has 
been the fruitful topic of elaborate research and hypothesis, owing to 
the interest connected with it both in a physiological and medico- 
legal relation. 

Previous to the year 1825, when John Evangelista Purkinje fortu- 
nately discovered the germinal vesicle of the unfecundated egg; and 
down to the year 1827, when Ch. Em. V. Baer detected the mammal 
ovum, whose germinal vesicle was detected by Coste; and the year 
1830, when Rudolph Wagner ascertained the existence of the Keim- 
schicht, or macula germinativa, all notions and opinions on the mammal 
ovum may be set down as naught — since the opinions of the learned 
are now based on the discoveries just mentioned, which have led to a 
complete revolution in many most important constructions of physio- 
logical action, and therapeutical indication and treatment. 

It would be bootless, therefore, to ask what the writers of an earlier 
date than 1825 may have supposed upon the subject of the corpus 
luteum. 

Dr. Carpenter, John Miiller, Thomas Schwann, Henle, and Huschke 
have not hinted at the vitellary nature of the yellow body. 

Dr. Henle, in his Algemeine Anatomie, says, " So weiss mann 
namentlich, wie die Grafschen Blaschen, in folge der congestion welche 
den fruchtbaren beischlaf folgt, erst anschwellen und den platzen, 
wahrend sie zugleich von Blutt angefullt werden, welches sie almah- 
lig entfarbt, organisirt, und in eine narbensubstanz verwandelt, die 
zuleszt verschwindet." — P. 894. 

In this paragraph, Dr. Henle attributes the swelling and the burst- 
ing of the Graafian follicle to the congestion attending a fecundation. 
He says the ruptured cell is filled with blood, which colors it, becomes 
organized, converted into a scar-like substance, and then, at length, 
disappears. 

Dr. Huschke, in his Treatise on Splanchnology, elaborately details 
the opinions of authors on the corpus luteum ; but nowhere alludes 
to the vitellary nature of that body. 



10S THE CORPUS LUTEUM. 

Dr. Gendrin, M. Maygrier, Dr. Robe:: Lee. Wharton Jones, M. 
Raciborski, Olivier D' Angers, M. Pouchet, make no mention of it — 
though they all enter into details, 

Dr. Montgomery, Dr. Swan, and, I think, Dr. P Prison, speak not 
of it. 

M. Flourens, and Iff. Velpeau, and Dr. Moreau, omit all allusion 
to the vitellary structure of the substance. 

Bernhardt, who was assisted in the construction of his Symbolxe ad 
ovi Mam. Hist, ante PrcEgnationem, by Dr. Valentin, in which ad- 
mired work is contained a complete deduction of the whole literature 
of the corpus luteum, alludes not to the idea. 

Von Baer's celebrated letter, De Ovi Mam. et Hominis Genesi, says 
of the corpus luteum. a: page 20, "Me judice, minime corpus novum 
est, sed stratum internum thecae majus evolutum" — which expresses. 
with sufficient clearness, the opinions set forth in the rest of his para- 
graph. 

Dr. Bischoff, of Heidelberg formerly, now of Giessen, in his Ent- 
wickelungsges chide der Saugthiere und des Menschen, says, at pasre 
33 : 

" Wenn mann die erste entwickelune des gelben Korpers, unmittel- 
bar nach austritt des eies, bei Thieren beobachtet hat, so kann mann 
dariiber nicht in zweifel seyn, dass die bildung seiner masse von den 
innern flache des Graafschens Blaschens ausgeht. Da sie nun hier 
die aus zellen gebildete memJbrana granulosa befindet, da sir zuers: 
als gelber Korper erkennbarre masse gleichfalls aus zellen besteht, so 
ist es wohl gewiss, das von einer starkeren entwickeluns: dieser zeHen 
der membrana granulosa, die ich auch in der Periphaerie des eies noch 
nachweisen werde, die bildung des gelben Korpers ausgeht." 

From this passage, it seems that Dr. Bischoff is not far from dis- 
covering what I suppose myself to have discovered ; I mean the vitel- 
lary nature of the yellow body of the ovary. 

It appears needless to make any further citation in this place. 

I shall here offer the remark, that if the concave superficies of the 
ovisac, or inner concentric, is really charged with the office :f pro- 
ducing or excreting the vitellary matter of the ovulum, which musl be 
admitted, even if we allow to that body the metabolic and plastic cell- 
force, (for it must, at least, be the producer of the cytoblastem of the 
cell,) there is no very great difficulty in admitting that the convex or 
exterior superficies of the same membrane may exercise the same 
functions as a dominant of its elective affinities; which must be sup- 
posed of every vital excrete. 



THE CORPUS LUTEUM. 109 

And such a supposition finds abundant support in the analogy of 
the organs ; as in the periosteal and medullary membranes of bones, 
for example ; which, under certain circumstances, are known to alter- 
nate their functional force ; the medullary membrane coming to be 
a depositor of phosphate of lime, instead of a remover ; and the 
periosteum a remover, instead of being a depositor of phosphate, 
which is its normal office. This mutation of powers, as to the mem- 
branes of bone, has so clearly been described by M. Flourens, in his 
admirable paper on the production of bone and teeth, in the Annates 
du Museum, that it needs no comment. 

But I am far from claiming this illustration for my view of the case, 
strong as I might deem it to be. It suffices better for me to know that 
vitellary matter is germinal matter, germinal cytoblastem ; and that 
the business of an ovary is to produce it ; and nothing else in nature 
can do it. 

As to the microscopic results at which I have arrived, I have no- 
thing more to do than tender them to the micrographers ; and I should 
feel most happy if these remarks, meeting the eyes of Dr. BischofF, 
or my kind friend, Dr. Pouchet, those gentlemen should deem them 
worthy of their attention, and confirmation or refutation. If they 
prove to be unfounded, I wish them to be confuted by better observers 
than I am. 

As to some other points of resemblance between yelk and corpus 
luteum, I have now to observe, that boiled corpus luteum becomes 
hardened, like yelk boiled hard. It is, in like manner, friable and 
granular, leaving a yellow stain on paper, like the stain from boiled 
yelk. 

Dr. Thomas Schwann found it evidently coagulated, granular, and 
friable, upon being boiled. 

In order to ascertain its odor, I threw a portion of corpus luteum 
on a live coal; — it gave out a strong odor of roasted eggs. 

Are the granules and corpuscles of the corpus luteum cytoblasts 
and cells ? 

I have not been able so clearly to make out their nuclei as to speak 
positively — I suppose them to be so. But Schwann, himself, who in 
one place seems to regard the nucleus as a sine qua non in cell-life, 
says, at page 204 of that most admirable and extraordinary volume 
the Microscopische Untersuchungen : 

"Die kernloser zellen, oder richtiger ausgedruckt, die zellen, in de- 
nen bisjetzt noch keine kerne beobachtet werden sind, kommen nur 
bei neideren pflanzen vor, und sind auch bei Thieren selten." Non- 



110 THE CORPUS LUTEUM. 

nucleated cells, or, more correctly speaking, cells in which nuclei have 
not as yet been detected, are found in the lower vegetables, and are 
also rare in animals. And he cites, as examples of the non-nucleated 
cell, the young cells within the old cells of the chorda dorsalis, the 
cells of the yelk of the bird's egg, &c. &c. 

Be the non-nucleated vesicle a cell or not, it is very certain that the 
milk corpuscle, and, probably, the chyle corpuscle, are of that nature, 
— and no one can contemplate the amazing reproductive power of a 
cell or spore of the saccharomyces cerevisiae, without admitting for it 
all the properties of the cell-force. It is to the last degree reproduct- 
ive, as are also many of the filiform fungi, the muscardine, &c. 

The question at last is, whether I have made a discovery interest- 
ing to the physiologist, the practitioner, and the jurisconsult. 

If I am right in my opinions, it must be interesting. 

As a resume, I say that my views are based upon the fact that — 

1. Equal masses of yelk and corpus luteum are equally yellow. 

2. They alike fill the tube, before the focus is got, with a brilliant 
yellow light. 

3. They alike consist of a pellucid fluid, in which float granules, 
corpuscles containing yellow fluid, oil-globules, and punctiform bodies. 

4. These bodies, placed on the same platine, and diligently com- 
pared together, exhibit the same forms, size, tint, and refractive 
power. 

5. Yelk, boiled hard, is granular and friable ; it is coagulated by 
heat. 

6. Corpus luteum, boiled, becomes hard, granular, and friable — 
it is coagulated by heat. 

7. Both substances, raw or boiled, stain paper alike of a yellow 
color. This experiment was repeated after Bernhardt, who says, 
" Cujus pigmentum aurantiacum (cor. lut.), admotis digitis adhseres- 
cebat."— P. 39. 

8. There is this difference : — The crushed mass of corpus luteum 
contains patches of laminar cellular tela, detritus, and blood-discs, 
forced out by the compressorium; which cannot occur in the yelk, as 
that is contained within a vitellary membrane, in which its corpuscles 
are free ; whereas, in the corpus luteum, they are confined by the deli- 
cate cellular substance lying betwixt the concentric laminae of the 
Graafian follicle. 

9. They refract alike. 

10. Projected on a live coal, they alike give out the odor of roasted 
eggs. 



THE CORPUS LUTEUM. Ill 

While I, of course, derive this view from perceptions of my own 
senses only, I ought perhaps to take leave of it here, committing it to 
more capable observers, in order to know whether they perceive it 
as I do. 

But, while I suppose that farther observations may probably con- 
firm my views, I see no objection why I may not now offer some re- 
marks, in the way of a rationale, upon the point in question, the more 
particularly, as I hitherto have relied only upon my own observations. 

I therefore state, that all living beings are results of the operation 
of a reproductive or generative force. 

This is true both as to plants and animals; with the possible ex- 
ception of certain fissiparous and gemmiparous creatures, as well as 
of certain sporiferous fungi, and some creatures of a higher scale, as 
the nais proboscidea, &c. I say of these, that they constitute a 
possible exception to the law of reproduction by germs. I do not 
say they are exceptions. 

This reproductive force has the same relation to the conservation 
of the vegetable and animal genera, as the force of attraction has to 
the conservation of the brute masses of matter of the universe. 

For it is obvious that, but for this force, all the genera would die 
out in a single generation, and yet it is apparent that nothing is more 
permanent than the genera, which extend from age to age, touching 
the beginning, the whole course, and the end of time. All the existing 
genera are the same to-day as at the commencement of the present 
cosmic career, and are destined to be so until the next great cataclysm 
of the globe. M. Flourens, in his work on generation, makes use of 
the mot, the saying, un etre collectif, a collective being, in speaking of 
the immutable permanence of a genus. This fine saying leads the 
mind at once to a view of the importance of the law of genesis by 
which so great an end is attained. 

It would, perhaps, be superfluous to say that, but for the exercise 
of this force, all morals would be nullified, and blotted out of the 
great scheme of Providence ; for, should the genera fail or die out, 
the earth would become a desert; no flowers to bloom, no corn, nor 
wine, nor oil — no insect to sport in the sunbeam — no song of birds — 
no lowing of cattle — no voice of man to acknowledge, and praise, and 
give thanks to the Giver of every good and perfect gift. Thus the 
whole scheme of morals would cease and be terminated, leaving no 
witness here to the power of God, beyond the senseless play of the 
elective and gravitating attractions. 

Is it not clear, then, that the laws of this great conservative force 



112 THE CORPUS LUTEUM. 

must be most important laws? Can such great forces have little or 
no concern with the regulation and co-ordination of the other life 
forces? I repeat, that for life they have the same importance as ap- 
pertains to the laws of attraction for the physical bodies of the globe. 

This force is the true development force, not only for the germ, 
but for the embryo, the fcetus, the child, the youth, and the man. 
He who shall know it truly, shall know the laws of life. 

It is not only a genetic, but a generic force. It determines the form 
and dimensions of the genera in an interminable succession of ages. 
No horrid passion, no wild lust, no insane desire can contravene the 
irreversible law of the distinction of the species and genera — "each 
after its own kind," — which, but for its provisions, would rush into 
chaotic confusion and mixture — whereas they are, in truth, trenchantly 
divided, and set apart, and for ever maintained, pure and unmixed. 

This force — this amazing force, is concentrated and summed up 
in a special animal or vegetable tissue. Nothing in animals, save a 
vitelliferous tissue, can yield or give out this force. It is the endow- 
ment of the ovarian stroma. It is the peculiar life-property of that 
concrete, and of nothing else. 

The stroma (Lager) of ovaries is a tissue developed and sustained 
by the combined agency of a spermatic or ovarian artery, and a sper- 
matic nerve. 

The spermatic nerves possess an intimate plexus and ganglionic 
relation to the spinal, the sympathetic, and the splanchnic systems of 
innervation — so that they are related, in fact, to all the organisms. 

Under the dominant indicative influence of the spermatic nerve, 
the ovaric artery, by its branches and termini, deposits the materials 
of the concrete of the stroma, with all its parts and mechanism. 

The general relation of the ovary to the whole of the innervations, 
while it enables it largely to influence them all, renders it liable to 
disturbance by their derangements. Its great influence is exhibited in 
pronouncing the single word sex, for the ovary is the sex of the 
woman, or the female. But if the ovary be her sex, then the whole 
peculiar physical, moral, and intellectual character of the female are 
derived from it, as their source and dominant — they are conformed to 
its wants, its powers, its offices — and often modified by its conditions. 

The materials of development for all the organs are derived from 
the blood, which may, without violent misapplication of the metaphor, 
be said to exist in a multilocular cyst, of which the cellulse are the 
different sanguiferous tubes and cavities of the vascular system. It 
is everywhere the same, and presents in each of the organs the same 



THE CORPUS LUTEUM. 113 

liquor sanguinis, and discs — so that although all development is at 
the expense of the blood, yet there is an additional, esoteric nerve- 
force, to compel the elective attractions by which every living concrete 
is produced. 

The physiologist knows that this esoteric force is nerve-force — and 
he will not deny that, for the development of both a general and spe- 
cial anatomic structure, it must possess what I desire to characterize 
as a generic force, else all development would be in spherical forms, 
and of the same constituent elements. 

No power can so modify the generic force of the nerves and blood- 
vessels of the cephalic extremity of the inchoate embryotrophe as to 
protrude from it a pelvis or a foot. Nor could a leg be possibly deve- 
loped in the place of a prehensile limb. Even in the quadrumana 
the law holds good. 

A liver whose development depends on its nutritious artery and its 
nerves, could by no means be formed at the caudal or cephalic pole 
of a mammal. It must always have its central position. No exam- 
ples will be found of a lung placed below the diaphragm. Hence, I 
say, the law of generic development is a law applicable not to the 
creature only as a whole, but to each of its several constituent parts. 
The whole business of zoological classification depends upon this 
order. 

This law not only operates during the embryonal, the foetal and the 
puberic development, but is in force throughout the whole duration of 
life, perpetually repairing the organs, and maintaining their generic 
forms, against the waste and detritus of life, until the cessation of life. 

The membrana germinativa of the ovum, which is probably R. 
Wagner's macula, (Keimschicht,) is an elliptical or circular disc. 
Let me repeat what I just now said, that no power could determine 
the production of the pelvic at the cephalic, or the cephalic at its pel- 
vic segment ; nor a leg from the thoracic, or of an arm from the iliac 
region of the disc. Hence it is true to say, that such disc is endowed 
at different parts of it with a generic force, operative only in that one 
sole direction. I say generic, since the idea is applicable to all ani- 
mals whatever, and to all the parts of animals. 

My motive for making the foregoing remarks is, that they might 
serve as an induction or basis, as to the generic force of ovaries. 

An ovary is developed by an ovaric arterial trunk and its branches,, 
drawing the vital current from the aorta or the emulgent, and attended 
by the spermatic nerves, which I regard as reproductive nerves, and 
generic in their powers. 
8 



114 THE CORPUS LUTEUM. 

I say reproductive nerves, since their innervative force is devoted 
to the evolution of germs : no other nerve has such a mission : I say- 
germs — perhaps I ought to say cytoblastem. 

If Huschke's pretty idea, that each Graafian follicle is a cast-off 
acinus of the stroma, carrying away in its fall an endowment of vital 
force rendered complete by active fecundation, should prove to be 
well-founded, I see no escape from the attribution of this reproductive 
quality to the spermatic nerve. 

But, without discussing the question of the aciniferous nature of the 
stroma, the same attribution of the nerve-power is right, even under 
the hypothesis of an independent cell-life — for a reproductive cell 
could not exist but for the vitellary cytoblastem provided by the 
stroma, which is a vitelliferous tissue, and only that. Nothing else 
is so. The nature of the cytoblastem must determine the differences 
of cells. The cell of an oak germ is different from the cell of a cab- 
bage germ, nor have they the same cytoblastem. 

But the sole office of an ovary is to produce or prepare germs — it 
is germiferous; and it is so by its power to form vitellary matter. No 
other combination or arrangement of animal materials can produce 
yelk or vitellus. 

The complete germ is contained within a vitellary membrane — 
which is the boundary of the yelk. In the mammals this yelk is 
microscopic. In the ostrich and the cassowary it is a very large ball, 
as it is in some of the larger ophidians, as in the coluber boseformis, 
&c. 

The matured germ contained within a yelk is spontaneously and 
periodically extruded from the ovary, in order that it may be fairly 
exposed to the contact of the malefecundative element — which should 
be deemed impossible while it is buried within the recesses of the 
ovarium, covered by the double tunic of the follicle, and beneath both 
the fibrous and peritoneal indusium of the organ. 

To effect this extrusion, this spontaneous oviposit, the inner con- 
centric spherule of the follicle is compressed, by the deposition on its 
external convex surface, of yelk grains, corpuscles, oil-globules, 
punctiform bodies, and pellucid fluid — the beginnings of the corpus 
luteum — which gives to the concave surface of the cell an appearance 
of corrugations or convolutions like those of the brain, and which, as 
they daily increase by the continued deposit of yelk matter on the 
exterior, constantly reduce the size of the interior dimensions of the 
follicle, urging its contents towards the least resisting point of the 
surface of the ovary, until, at length, the porule being opened, by the 



THE CORPUS LUTEUM. 115 

dehiscence of the coverings or capsule, the ovulum escapes into the 
fimbria, or falls with the peritoneal sac. 

After the escape of the ovulum, the yelk-producing force is not ex- 
hausted immediately, in all cases ; hence the growth of the corpus 
luteum continues for a time whose limit is not yet known. 

It is a periodical exacerbation of biotic force, that matures and 
bursts the Graafian cell. When the process of completing a germ 
and expelling it has been finished, the exacerbation ceases sooner or 
later, and a new periodical exacerbation of this strange life-force — or 
germ-producing force — is devoted to the maturation and spontaneous 
oviposit of another ovulum, and so on in succession, during the men- 
struating life of the woman; at every successive pairing season of 
birds; and at the annual rutting time of the more considerable mam- 
mals, and in all the migratory fishes at stated times. 

It surprises me to see that many able and distinguished writers still 
cling to the antiquated notions as to the ovaric fecundation, which 
M. Pouchet has shown to be an impossibility. It appears to me that 
my view of the vitellary composition of the corpus luteum, and the 
mechanical result of its accumulation in effecting the oviposit, ought 
to be received as satisfactory rationale of the germ-depositing func- 
tion. The fecundation of germs is a mystery which I deem beyond 
human cognition — and likely ever to remain so. The inquiry into the 
corpus luteum is far more feasible and practicable. No woman can 
menstruate but coincidently with, and in consequence of, the oviposit. 
Every oviposit is followed by a corpus luteum, which is larger or 
smaller, according to circumstances. Many women have scarce dis- 
cernible ones after conception — others have very large ones. The 
true and false corpora lutea differ only in magnitude — not in their 
essential nature. 



PART II. 
THE PHYSIOLOGY OF REPRODUCTION. 



CHAPTER VI. 

MENSTRUATION. 

Women are subject to a discharge of blood from the genitalia, which 
returns very regularly once a month. This monthly periodicity of 
the bleeding has given it, among many people and languages, the 
name of menses — menstrua, menstruation, catamenia, mois, monat- 
liche, menstruacion, mese, &c. Among us, it is called courses — 
periods, terms, monthlies, monthly sickness, unwell, times, and a 
variety of other names, hints, and allusions, that need not be summed 
up here. 

The discharge is not met with in children, in unmarriageable girls, 
nor in old women. It appertains to women only as long as they are 
capable of conceiving. They cease to be child-bearers when they 
cease to enjoy the power of menstruation. 

The first appearance of it is noticed among us at fifteen, but many 
are found to produce it at fourteen years, and some at thirteen and 
a-half years of age. In general women have ceased to menstruate 
after they have passed their forty-fifth year — yet there are vast num- 
bers who continue to be menstrual until they attain the age of fifty 
years. It is rare for a healthy woman to cease menstruating before 
she is forty years old ; some, however, cease at thirty-six. 

I said that the catamenial discharge is blood. It amounts to from 
four to six fluidounces of blood at each term. This is the rule — the 
exceptions are, that some women do not eliminate more than one or 
two ounces each time, and that others never lose less than ten or even 
sixteen ounces of blood. 

For the most part, as soon as the menses are perceived to begin to 
flow, the woman applies a T-bandage, consisting of a napkin, called 
the guard, folded like a cravat, which is pressed against the genitalia, 
while the ends are secured to a string or riband tied around the body 
above the hips; but I have seen some, not a few women, who assured 
me they had never used any other precaution than that of putting on a 



MENSTRUATION. 117 

thicker petticoat for fear of the exposure of their state. Such persons 
can be very slightly hemorrhagic, since the want of a guard-napkin 
would be sure to expose their condition by stains of blood upon their 
feet or stockings. Many female patients have assured me they never 
use less than a dozen napkins upon each catamenial occasion — and 
fifteen, and even twenty such changes are not very rare in the history 
of healthy menstruations. An ounce to a napkin is not an excessive 
computation. 

Perhaps the student will acquire the justest idea of the ordinary 
quantity, by settling it in his mind, that four to six ounces is the most 
common rate for each normal menstruation. 

It seems to be a very indifferent matter for the health of women, 
whether they menstruate freely or not, provided each one is regulated 
by the habits, wants and normal forces of her own economy. 

Each female in menstruating obeys the law of her own special sys- 
tem, and not that of another woman's system; hence, if she habitually 
loses four ounces, and is well, no attempt ought to be made to aug- 
ment the amount of the discharge ; since her four ounces are what 
she requires, and not twelve ounces. On the other hand, one who 
has for years lost twelve ounces at each menstrual return, might be 
deemed sick, in case she should dispense four ounces and no more. 

Each catamenial period continues from three to five days ; so that 
the subject is not free from it more than from twenty-three to twenty- 
five days at a time ; and there are many examples to be met with in 
which the period of its duration is not less than seven or eight days 
for each menstruation. 

In the duration of the flow, as well as in the number of fluidounces 
discharged, each woman obeys a law of her own nature, and if that 
be fulfilled, her health is good, as to the duration. The young phy- 
sician should not, therefore, feel constrained to take in hand a case, 
because the number of menstruating days of his patient might be less 
than that of some other woman. 

Much disputation has attended the investigation of the menstrua. 
Some writers aver that the discharge is a secretion, and not an effu- 
sion or hemorrhage — some declaring it to come from the veins, and 
others from the arteries of the uterus. At present, these disputes ap- 
pear to be at an end. The valuable researches of Purkinje, Coste, 
Von Baer, Pouchet, Negrier, Bischoff, and others, have rendered it 
clear that the catamenial fluid is blood. Blood cannot be secreted. 

I am aware that the Student of Medicine, I mean the younger sort, 
will be apt to find himself, here, in a sea of doubts and perplexities 



118 MENSTRUATION. 

arising from his respect for authors ; for he will have studied some of 
the older books, from which he will have derived notions difficult to 
eradicate from a young mind, in which they have taken deep root. 

Let him refer to the article on the ovaria, where he will find, that 
all that has been said upon the nature and causes of menstruation 
prior to the year 1825, is nonsense ; and that our real information 
began to acquire some philosophical certitude from the moment of the 
discovery of Purkinje's vesicle, which cast so bright a dawn upon the 
nature and laws of reproduction ; and that, by the labors of physi- 
ologists and naturalists since the said date, 1825, our dawn has grown 
to be a great shining light, under which things are clearly seen and 
understood, that were formerly wholly unknown or imperfectly com- 
prehended. In this department, then, let the student turn to the 
moderns. It will be proper for him, in a more advanced scholarship, 
to learn what our predecessors erroneously deemed of this matter. 

I repeat, then, that the menstrual fluid is blood ; but it is impure 
blood — it is impure only from the admixture of a quantity of mucus 
and epithelial scales. 

It is rich in blood-globules, and in serum ; and when it is abundant, 
hurrying itself from within the genital cavities, it is nearly pure 
blood. On the contrary, when it oozes slowly and tardily away, 
resting, perhaps, a long time in the cavity of the vagina, before the 
sphincter vaginae allows it to escape, it becomes slimy from the plen- 
tiful addition of mucus to it. This is especially the case in such as 
have a vaginal leucorrhcea, or in those who have the albuminous leu- 
corrhoea that is produced from the crypts and glandules of the canal 
of the neck of the womb. 

The beautiful engravings given to us by M. Pouchet in the Atlas 
of his Theorie Positive, are, doubtless, absolute faithful representa- 
tions of the microscopic view of the menstrual fluid. They ought 
to be conclusive in settling our opinions as to the nature of the genital 
discharge, not in women alone, but in various animals of the mam- 
miferous quadrupeds. 

It is not in every one of the older authors that erroneous notions 
are to be met with as to the quality of the menstrual discharge. 

To cite one distinguished example — Haller says: "Sanguis men- 
struus de sana, neque immunda foemina, rubore, calore, odoris ab- 
sentia, nihil ab alterius fceminae sanguine differt. Lentorem aliquem 
possit mucus admistus addidisse." — Physiologia, lib. 28, sect. 3. 

I may add here that Madame Boivin, whose knowledge of the 



MENSTRUATION. 119 

whole topic is not inferior, perhaps, to that of any other writer, de- 
clares that it is blood like that from a vein. She says : — 

"La qualite du sang des menstrues, ne parait pas different de celui 
qui circule dans tout le systeme, lorsque la femme est saine, bien 
conforrnee, et qu'elle fait usage des moyens que la sante et la pro- 
prete exigent.'' — Mad. Boivin, Art. des Ace, 105. 

The few opportunities I have had of observing the appearances of 
the catamenial fluid, have been insufficient to enable me to come to 
positive conclusions: since healthy women admit of no such investiga- 
tion; and the morbid specimens, which are the only ones submitted 
to us, are not to be considered as samples of what flows naturally. 
Madame Boivin's account is, therefore, more worthy to be relied upon 
than that of any physician whatever. Madame B. can speak of the 
normal, and the medical man can only have access to the observation 
of an abnormal state or character of the discharge. 

The Student will pay greater respect to facts in making up his 
opinions than to any man's opinions. He is aware of the constitu- 
tion of healthy blood, whose analysis is in one thousand parts — 

Corpuscles ----- 127 

Albumen 80 

Fibrine 3 

Water 790 



1000 



If such be the true results of analysis of the blood, and I take it 
that it is so, then let the Student compare it with the analysis of the 
fluid discharged by women in menstruation. 

M. Brierre de Boismont, in his work on menstruation, at p. 172, 
gives this analysis by Denis, of the menstrous fluid of a healthy per- 
son, aged twenty-seven years : 

Water 825.00 

Globules 64.40 

Albumen 48.30 

Extractive matter - - - 1.10 

Fatty " 3.90 

Saline " 12.00 

Mucous " - 45.30 



1000.00 



120 MENSTRUATION. 

Rindskopf (Simon's Chemistry of Man, 337), found the menstrual 
fluid to be acid, and composed of 



Water - 


820.830 


Solid residue - 


179.170 


Salts 


10.150 


In a second analysis, he found 




Water - 


822.892 


Albumen and hsemato- globulin 


156.457 


Extractive matter and salts 


20.651 


•anz Simon's Analysis was — 




Water - 


785.000 


Solid constituents - 


215.000 


Fat 


2.580 


Albumen 


76.540 


Hsemato-globulin 


120.400 


Extractive and salts 


8.600 



Dr. Letheby [London Lancet, May 2d, 1845), made an analysis of 
fluid detained by an imperforate hymen. It consisted of — 

Water 857.4 

Solid constituents - 142.6 

Fat 5.3 

Albumen - 69.4 

Globules ... 49.1 

Hsematin - 2.9 

Salts - 8.0 

Extractive - - - 6.7 

These analyses, I hope, may serve to convince the Student that the 
menstrual fluid is produced by effusion or extravasation, or hemor- 
rhage, and not by an act of secretion. There can be no analogy be- 
tween an act of secretion like that of the liver, kidney, or salivary 
gland, and a clear outflowing of pure blood of the capillary vessels, 
or other tubes that afford the outlets for such discharge. I repeat that 
there can be no blood secreted. 

The cause of menstruation is now, nearly on all hands, admitted to 
exist in the ovaries, and to be connected directly with the periodical 
evolution and discharge of the mature ovulum, a process denominated 
ovulation. 

When a woman's body, who has perished while menstruating, or 



MENSTRUATION. 



121 



soon after the performance of that act, is examined by the anatomist, 
he always finds upon the surface of one of the ovaries, a small bloody 
spot ; sometimes as large as the head of a very small pin, and some- 
times larger or smaller. If a delicate probe be pressed upon this 
bloody point it sinks into the ovary, the point descending into a cavity 
which contains a minute clot of blood. This cavity is the emptied 
Graafian vesicle, from which the ovulum has made its escape by pass- 
ing out through the bloody pore in the ovarium. The ovulum may 
be supposed to have fallen into the pelvis, where it is not to be seen, 
on account of its minuteness — being invisible to the naked eye. Its 
presence in the pelvis could not do any harm, if it were not fecun- 
dated. Perhaps, if it were fecundated, it might be discovered, by 
slitting up the Fallopian tube, in the canal of the tube, or it might be 
traced into the womb itself. The Student can readily find it in the 
cornu of the sheep's womb. 

The cut that I subjoin is a good representation of the appearances 
above mentioned, in the ovaries of a young female, who died eleven 
days after the commencement of her discharge. As she perished 
with a violent disease, it is possible that the healing or reparative 
processes may have been more tardy than they are in a healthy girl. 

Fig. 51. 




When the specimen was brought to me, I perceived the porule 
which had allowed the ovulum to escape, and I inserted a fine probe 
in it and down to the bottom of the -crypt* The edges of the pore 
being cleansed, the aperture, it was evident, had been opened by 
absorption to allow the contents to escape. The whole of the cir- 
cumjacent tissue was highly injected, as it is always found to be 
under such circumstances. 

With a scalpel I made an incision which split the pore, and sunk 
down to the bottom of the crypt, or emptied cell of de Graaf. In this 
crypt, I found a clot of blood, which filled it well. 



1 i C MKHSJXMIFATIOir. 

Upon turning one of the flaps over, as in the figure, and after wip- 

LiiL" tie ine: sniaces tie an. :i: :: in irati:i :: ::: iiii.^ rieniraie 

~as vis;:.;. 

I: ~:--5 :-:iv:ii.ri like tie ::i~"t in: is z: tie iraii: &l: tie seriate 
is a.i~ its s: ztmiitei. betaise tie iiieints: tnzeitrit ::at ::' tie 
Gmid: ttiiie is pressei in— a: is tt~ iris tie i:::: ;:' tie spienle. 
by tie n*"!,; ie: :si: tiat takes place bet— ix: i: aii tie : ate: : : ::. 

Tie i . : i 5 : i?.s eiiea-trei :: represei: tits appearaise :: :ie etn- 
~:i\::i:is: ni hiiLziz- ie ias i:ie it — ei. -.---: i ;:;ii n: if 
t! T::ri tiat a~ til ei^Ti-iig ::iii repres-eit siti ieitate miii- 
tatitis ::' init is tie iie: ttities :: :ie : :pi e:-p ie:e ema-rer. 

T: :i:se ~i: nigit iesi:e :: see :iis appeaiaite as i: reaiy is. I 
rettnneii ai iis:e::i:i :: :ie :~a.:ies :: tie s:~. :: a :e:e:ei:e ::■ 
tie ex: lisite ftitrei eir:a~i:t:;s :: Ptitiet: raiit liariv :ie ines 
1 : i / : £ : : i ni 7. :■: :ie Atias :: :ie T'.i: ■ Pterin Tie 
sane tiate, a: iiates 1 aia i\ ttitaiis verv J ist exrressitis :: tie 
raiaxte :: :ie rentes tipn tie si::i:e tt tie naiii:. :'::ia — irite 
tie :-iirS itaie tie : r esttee. 

I:, i "."iiii:e i::i^i.t iae.tb:ee veers siite. tie nteras aii —aria 
::' = • :::: ienaie. — i; iiei siiieiiy — iiie neistriatii^;. Ii tiis 
spetinex I ietettei tie bitoiy p-ttxie Mi tie :ryp: beieati. iiiei 
— ii:. tie ttariina, Tie ta~ irv ::' tie ":iti ttxtaixe: bitoi :: tie 
nieises. 

Let the reader refer again to the cut, Fig. 51, -where he will End, 
ti: :i tie tin: :~iz~. tie nark t: ai ii:isi:i. I iti :iat iiti- 
sion upon the centre of a late cicatrix, which I supposed to be the 
s:a: ::' tie i i s t :: axteteieit neist:xni:i. Tie titatrix — is :::;..- 
plete, but upon cutting down through it, I came upon the cavity of 
the crypt, which still contained the remains of the old cloL This 
old clot had become, in a measure, granular and dryish. 

There were other cicatrices of still older menstruations ; and I doubt 
no£ that if the young woman had had during her life forty menstrua- 
tins, sir bai Lai ::rrv :i:atri:es t: tie vr:ni> ;; nptires :: tie 
Graafian cells, through which the ova had escaped. 

I do not mean to assert that an anatomist ought to be able to count, 
upon the oTaria of a subject, the number of menstruations, by count- 
ing the scars; for, many of the succeeding ruptures must take place 
through old scars, thus confounding or blending them together. 
Vv "i at I wish to express is, the opinion that a woman never does men- 
struate without rupturing a Graafian follicle and discharging an ovu- 
lum, and leaving a scar of the opened hila. 

tnai nav bieei ti:.i tie "■ :::_': as sie xaav bieei i:::i tie 



MENSTRUATION. 123 

lungs, the Schneiderian membrane, or the stomach; but she does not 
menstruate except she also performs the offices of the periodical ovu- 
lation. 

From the foregoing it appears that the doctrine, as to the cause of 
menstruation, is as follows. 

1. Up to the period of puberty, the ovaria do not contain any ma- 
ture or ripe ovules. 

2. At the completion of the puberic age, ovula are matured within 
the Graafian cells, and the woman continues to mature or ripen them 
as long as she continues susceptible of impregnation; that is to say, 
from the attainment of complete puberty, which is generally in the 
fifteenth year of her age, in this country, until the age of forty-five, or 
change of life. 

3. The ova contained within the Graafian follicles are matured 
periodically — in women, once a month ; in other animals, at stated 
intervals; in the larger animals, once a year; or even with still 
longer intervals, as in the elephant, and creatures that carry the young 
in the womb more than an entire year. 

I need only advert to the universality of the law of periodicity as 
to the evolution or maturation of germs; and I do not find myself 
called upon to explain why there should be, in the economy of Provi- 
dence, a law of periodicity for the great purposes of reproduction. It 
suffices to perceive that it could not have been otherwise, without 
introducing the greatest disorders among the living creatures under 
the dominion of that same all-wise Providence. 

In the vegetable, as in the animal kingdom of Nature, we clearly 
perceive, on every hand, the wide-spread reign of this law; for we 
see the forests annually repeating the sexual act upon which their 
genera depend for a perpetual renewal. The grasses, and flowers, 
and fruit trees, raise this great annual hymn to show the continued 
will, power, and beneficence of God ; and the whole of the insect 
tribes, the worms, the fishes, birds, and mammals, are under a perfect 
obedience to the same great force. 

The influence of domesticity has, by Fred. Cuvier, been shown to 
have a power not dissimilar from the power of civilization, to modify, 
in some degree, the operation of the reproductive forces. Under this 
modifying force, we find certain of our domestic quadrupeds and birds 
to have lessened the duration of their reproductive intervals, but such 
instances ought not to change our convictions as to the universality, 
or of the necessity, of this strange periodicity. The modifying power 
of protection, of abundant and more nutritious food, of habit, &c, 



124 MENSTRUATION'. 

might well be supposed to add a greater vigor to the physical opera- 
tions of our domestic creatures. There is no denying such influence 
for those portions of the Human race in which the arts of civiliza- 
tion, under the protection of wise and beneficent codes of law, permit 
the human form and forces to acquire their highest perfection. 

As I have, in my Letters to the Class, treated, at considerable length, 
upon the evidences of the universality of the reproductive periodicity, 
I shall not repeat those details in this place, but beg leave to refer the 
student to Letter XXVIIL, p. 364. 

I take it for granted, then, that the ovarium has power to mature 
one Graafian follicle at a time, during which process, the upper seg- 
ment of the spherule rapidly rises above the surface of the ovary, 
becomes extremely thin, and finally opens by a delicate pore, through 
which the ovulum, or little yelk containing the ripened germ, escapes 
into the pelvis, or is carried down to the womb, after being ingurgi- 
tated by the infundibulum of the Fallopian tube. 

4. During the whole menstrual life of women, extending from 
the fifteenth to the forty-fifth year of their age, the stroma of the ova- 
ries, which contains, perhaps, myriads of germ points, r 4 is ripening- 
many Graafian follicles, and if those that are situated at considerable 
depths beneath the surface should be examined, we might find our- 
selves at a loss to know which, of a number of them, would be the 
first to be fully ripened. 

As to those that have risen near to the surface, there might be less 
hesitation to point out the ripest one. They all grow, perhaps, pari 
passu, during the greater part of the inter-menstrual period, for we 
discover no signs of extraordinary activity in their evolution, except as 
the woman approaches the time for being taken unwell. As that time 
approaches, she exhibits the constitutional and local signs of increased 
sanguine determination to the organs within the pelvis. She has lum- 
bar, and sacral, and sur-pubal pain, and fullness or tension, with heat 
or warmth and weight, all of which symptoms are relieved and car- 
ried away with the torrent of the menstrual hemorrhage, which is the 
bloody and external visible sign of the extraordinary vascular and 
nervous excitement of the internal genitalia. Which of the genitalia ? 
Is it the uterus, or the ovary, that is the focus of this sanguine tour- 
billon*! 

In all ovaries containing mature follicles, whether of woman, or 
of quadrupeds, that I have examined, I have noticed the undeni- 
able evidences of increased vascular activity, as seen in the nume- 
rous arterioles and venules, as well as capillary tubes, in the imme- 



MENSTRUATION. 125 

diate vicinity of the developing follicle. See the wood cut Fig. 48, 
page 102, copied from Prof. Coste's atlas. 

These circumstances lead me to the conviction, that the ripening 
ovulum, in the last days of its progress to perfection, is hurried through 
its processes by a violent, almost explosive, augmentation of the phy- 
siological forces resident in the stroma. Such augmentation of biotic 
activity can come only through the nerves and blood-vessels of the 
part. But, seeing the potent, nay, the dominant influence upon the 
whole life-force, of the ovaria, whose stroma is the essence, in physics, 
of the female sexual nature, what wonder have we when we perceive 
that influence extending itself to the whole reproductive apparatus, 
and even to the whole moral and physical being ? Is it not vigorous 
enough to excite the affluxionor molimen of the monthly hemorrhage? 
It is the periodical intensity of the ovaric force that, exciting the so- 
matic energies in general, occasions the phenomena of menstruation. 

5. During the last days of the developing of the ovarian ovulum, the 
vascular circulation and the nervous intensity of the organ are greatly 
augmented — a state which passes beyond the boundaries of the stroma 
itself, and being propagated to the uterus and vagina, renders them 
the seats of a sanguine affluxion and engorgement. 

Under such circumstances, the uterus increases in weight; it ac- 
quires a redder hue, is more sensitive, and sinks somewhat lower in 
the pelvis. 

From such engorgement and affluxion it is delivered by means of 
the mensual hemorrhage, which escapes from the vessels on the inner 
aspect of the womb, falls into the vagina, and thence flows upon 
the outer surface of the external genitals ; and it is called menses, 
catamenia, show, &c. &c. It is pure blood, mixed with uterine, 
tubal, and vaginal mucus, and epithelium. 

Such is the doctrine of menstruation, a doctrine that resolves itself 
into one of local plethora or hypersemia, which liberates the physi- 
cian and the philosopher from the bonds of every ancient prejudice on 
the subject, and shines upon his therapeutical and chirurgical path with 
a light so strong and clear, that he need no longer stumble and grope 
amongst a chaos of vulgar, yet time-honored, opinions and methods. 

It is difficult for me to imagine that any reasonable person could, 
after reading the foregoing statement of the doctrine, entertain any 
the least doubt of its sufficiency or its truth. 

It has been established by the labors and good fortune of Coste, 
Negrier, Gendrin, Lee, Jones, Raciborski — and more than all, byPou- 
chet of Rouen. I am far, however, from withholding the expression 



126 MENSTRUATION. 

of my admiration for the indispensable researches of Purkinje, Von 
Baer, Wagner, Thomas Schwann and BischofF. It is the doctrine, 
not of the humble author of this volume, but of the celebrated and 
honored men whose names I have above recited. 

The former doctrines of menstruation give us no clear indications 
of a therapeutical treatment of the disorders so frequently connected 
with that periodical act. It was foolishness to assign as a cause of 
the menstrual periodicity an influence of the moon, since observation 
and experience showed to all inquirers that there is no coincidence 
of the act with any particular phase of the moon, some women being 
always to be found just beginning, just concluding, or midway be- 
tween the periods of monthly evacuation. 

The doctrine of a general plethora, peculiar to the sex, and required 
of them as a means to the end of reproductiveness, was easily confuted 
by the always obvious facts of persons menstruating regularly even 
when very much reduced by sickness or other causes of oligsemia. 

The true doctrine was that of a local plethora, or, in other words, 
a state of periodical hyperemia of the reproductive organs; and now 
that doctrine is not only established, but it is made plain to the under- 
standing, for the periodical paroxysm of stromatic force, that hurriedly 
concludes the ripening of the most perfect ova, establishes the affluxion 
which fills the capillaries of the reproductive organs, and engorges 
them, or renders them hyperaBmic to the point of compelling the 
monthly hemorrhage by which the hyperemia is removed, leaving 
behind it no trace of indisposition. 

This admirable exposition, for which we are so greatly indebted to 
its discoverers, preserves us from the most serious errors in our prac- 
tice ; while it reveals to us a vast deal of information as to the state 
and wants of women in whom the catamenia have become disordered, 
or in whom they have never appeared. 

Heretofore, physicians have looked to the bloody sign alone as the 
act; hereafter they will be likely to look upon the maturation and 
discharge of the ovarian ovule as the physiological act of menstrua- 
tion, and upon the sanguineous effusion only as the sign that the 
physiological act has been or is being performed. 

True menstruation is the regular periodical evolution and expulsion 
of an ovule; it is ovulation. This act may suffice to cause the wo- 
man to bleed mensually, or it may prove insufficient to that end. It is, 
for the most part, a matter of indifference whether it does or does not 
cause the mensual hemorrhage; the essential thing is to mature and 
deposit the ovule. 



MENSTRUATION. 127 

There are many circumstances of the menstruating girl or woman 
that are able to prevent her from bleeding, notwithstanding she enjoys 
all the other faculties of a perfect health. 

As to the woman. A married woman who conceives in the womb 
does not necessarily upon that account cease to mature and deposit 
her germs. On the contrary, she retains a strong tendency to men- 
struate up to an advanced period of gestation. Yet, she does not, 
as a very general rule, discharge the mensual fluid. But, there are 
many examples of women who do actually retain, in the early months 
of pregnancy, the power to pour out from the vessels of the womb 
the usual product of menstruation; an act that leads them to abortion. 

Probably a woman has a much greater liability to abort at the time 
of her mensual crises than at any other time; which can only depend 
upon the occurrence of the catamenial effort under the periodical in- 
tenseness of the germiferous force. 

The same is true of the woman who gives suck. 

A woman with a nursling at the breast does not, in general, men- 
struate until the child is seven months old ; and thousands of women 
do not menstruate until they have weaned the child. Yet these wo- 
men are liable to become pregnant; indeed, there are many who do 
become pregnant again and again before they have weaned, and be- 
fore they have had the return. Such facts are proofs of the continu- 
ance of the germ production in the ovary as well as of the ovulation. 

As to the young girl. A young female who has been brought up 
at home, in the country, is rarely sent to a boarding-school to finish 
her education without soon finding herself the subject of a catamenial 
derangement. She may have been perfectly regular at home ; but, 
soon after she takes her place upon the school form, and devotes 
many hours to study, the menses are apt to be suspended, and to 
remain suspended until she leaves the school and ceases to consume 
her nerve-force in those mental or intellectual operations that require 
for their effectuation all the biotic force she is capable of evolving. 
The consumption of this force leaves her destitute both of the power 
and the necessity to discharge the menstrual blood ; not depriving her, 
however, of the force required to fulfil the true physiological office, 
the ripening, to wit, and the discharging of her monthly ovulum from 
the stroma. Her ovulation goes on regularly and she is well, though 
not visibly menstruous. I have found many young women thus affect- 
ed ; but, the health being in all other regards perfect, I have not ven- 
tured to interfere, beyond the interference of recommending a lessened 
intensity of mental labor, a more abundant and exciting diet, and a 



128 MENSTRUATION. 

proportional amount of daily exercise in the free air. Such amenor- 
rheas cease as soon as the girl leaves school. 

The pregnant and the suckling woman do not menstruate because 
the life-force is fully occupied otherwise — they fulfil the germiferous 
law — in the same way — the studious and sedentary school girl does 
not menstruate visibly, because her nervous mass is already pre- 
occupied. She performs, however, the physiological act of the ovi- 
ponte — or ovulation. 

Let the woman miscarry — or wean — and she will soon perceive 
the visible sanguine sign of her ovi-ponte. Let the over-tasked 
school girl cease to call upon her nervous mass for impossible sup- 
plies of biotic force, and her menses will speedily return and be 
regular in time and in sum ; for her nervous energy is no longer mis- 
directed and improperly consumed, in studies beyond its supply. 

It is time to say a few words upon the catamenia as connected with 
the computation of the commencement of pregnancy. 

I presume that a woman can not be fecundated except it be coin- 
cidently with the ovi-ponte. 

As a rule, then, a woman is liable to become pregnant only at and 
about the periods of her monthly sickness, and in computing the 
commencement of pregnancy we shall commit few errors if we begin 
the count at the day following that on which the flow ceased. Two 
hundred and eighty days should be allowed as the usual duration of a 
gestation. 

One who is regular ought to see every twenty-eighth day. If she 
sees for three days only, then she ought to be twenty-five days with- 
out seeing. 

In what portion of these twenty-five days is it that she is liable to 
impregnation ? Dr. Pouchet says that the liability extends to twelve 
days after the drying up of the discharge, and not beyond that time. 

It is, perhaps, rash to say so; and yet it seems improbable that the 
ovule should retain its vitality without fecundation, so long as twelve 
days after its escape from the follicular pore. 

The Jewish law commands the woman to abstain from the hus- 
band's bed until she have become clean. She is unclean eight 
days after the disparition of the last drop. Several Jewish females, 
having numerous children, have informed me that they have reli- 
giously observed this law in all their marriage. If these women 
spoke truly, they give incontrovertible evidence that the fallen ovule 
retains its fitness for impregnation, not only during the eight days 
subsequent to the drying up of the courses, but even longer, since we 



MENSTRUATION. 129 

know not precisely at what period of the mensual act the ovule 
departs from the cell. In the case mentioned on page 122, of the 
young girl whose womb and ovaria were given to me by Dr. J. Wal- 
lace, the patient died while menstruating — and the uterus still con- 
tained a certain quantity of the menses. Yet here the crypt was open 
and the ovule had escaped. It might be fecundated as soon as the 
menses should disappear. 

I repeat that we do not, as yet, know at what period of the men- 
sual act the vesicle bursts. The above example proved to me that 
the rupture took place in the young girl before the drying up of the 
discharge. So that, in the case of the Jewish women, if the same 
rule holds, we perceive that the ovule may be discharged, and yet 
retain its vitality without fecundation for eight days, and for more 
than eight days. 

In July, 1848, a young girl destroyed herself by taking arsenic, 
just before the expected return of the menses. Dr. Wistar, of this 
city, who examined the body, informs me that in one of the ovaries 
was a blood-red spot the size of a lentil. There was no absolute rup- 
ture of the crypt as yet, nor any blood in the uterine cavity. 

After the foregoing, I am clearly not called upon to say at what 
precise period after the courses, a woman cannot possibly conceive. 
I have no doubt there is such a period. Time, and opportunity to 
observe, can alone settle this point. The celebrated case of the 
birth of Louis XIV., and the advice of the court physician relative 
thereto, ought not to be cited, since they have none of the charac- 
teristics of rigorous truth. It shows, however, the old date of opinions 
on this point. 

I am for the present very willing to believe, with M. Pouchet, that 
a woman shall not conceive later than the twelfth day. 

There are questions connected with this topic that ought not to be 
lost sight of by the diligent student, who desires to prepare himself 
upon all the points of a professional duty. For example — 

Some women are to be met with who never menstruate, and who 
yet preserve a most perfect physical and mental health. 

Among these exceptional creatures, those are to be found in whom 
the ovaria or the uterus has not been developed. Dr. Renauldin, on 
the 28th of Feb. 1826, reported to the Royal Academy of Medicine, 
the case of a woman who died at the age of fifty-two years. She had 
never had any appearance of menstruation. The breasts were not 
developed. She had only a cervix uteri, which was of the size of a 
9 



1 30 MENSTRUATION . 

writing quill — no womb-proper — and the ovaries were scarcely de- 
veloped. 

Such a woman could not menstruate for the double failure of uterus 
and ovary. There could be no sexual passion — indeed, such a crea- 
ture was scarcely sexual. 

When Percival Pott, the illustrious surgeon, removed the ovaria of 
his patient under an operation for hernia — he took away with them 
the power of menstruation. There are numerous examples of females 
who did never menstruate, owing to the absence of the ovaries. 

As to the cases of absence of the womb, they are less rare than the 
former, and they ought not to be lost sight of by the inquirer, lest he 
permit his ignorance to lead people into a grievous unhappiness. A 
woman ought not to be married who has never menstruated, until it 
shall have been clearly ascertained that she is not amenorrhoeal from 
faulty development. 

I have seen two pretty women who were suffered to marry before 
it was ascertained that they had no wombs. 

Any attempts that were made in either of these cases, to bring on 
menstruation, are well fitted to cast ridicule upon the physicians. A 
physician should never be other than cautious in all his dealings with 
cases of absent or suspended menstruation. I state the following 
instance, in order to show the evil effects of a want of medical cau- 
tiousness. 

Mrs. Blank, aged twenty-two and a half years, was married to her 
present husband more than two years ago. She is of a middling 
stature and a fair complexion, and presents all the exterior appear- 
ances of a person in perfect health. 

She is not fat, but has a certain embonpoint, a good tournure, 
and a very feminine and most agreeable expression of countenance. 
She is, indeed, a handsome woman. 

She has never menstruated, nor has she suffered pain, or any severe 
attack of any disease. Seeing that she did not menstruate at the pro- 
per period, medical advice was sought and followed in the treatment 
of the case. The treatment was unsuccessful, and she was married 
with the expectation of her friends that the union would be followed 
by an eruption of the catamenia. The mammae were, at the period of 
the marriage, well developed, and the pudenda was amply supplied 
with hair; indeed, all the phenomena of a perfect development of the 
sexual system were present except the menstrual office. 

The husband found, however, that some unknown cause acted as 



MENSTRUATION. 131 

an impediment to the congress, and after more than two years of con- 
cealment, he consulted me on the subject. 

An opportunity being allowed to me for a full investigation in pre- 
sence of the mother, I found the external organs perfectly formed, the 
mons large, the labia and the nymphse as w T ell as the clitoris, perfect, 
and the os magnum of a natural appearance, but the vagina was a 
mere cul-de-sac, not more than two inches and probably less than 
that in length. Upon pressing the point of the finger strongly against 
the bottom of the cul-de-sac, it seemed to have no connection with 
any part above it. 

I requested the lady to lie on her back; and introducing the index 
finger of the right hand as far as possible into the rectum, I explored 
with it the excavation of the pelvis, in order to discover any tumor or 
organ that might be contained within the cavity; but as all the tissues 
were ductile and very yielding, I began to suspect that there might 
be no womb at all in the case. Therefore, laying the fingers of the 
left hand upon the lowest part of the hypogaster, and pressing them 
firmly towards the finger that was used in exploring the internal parts, 
I found that they could be brought so near to each other as to make 
it perfectly clear that there was no womb in the case, or I must have 
felt it, so near was the approximation of the finger of the right to 
those of the left hand. 

Having by the most careful exploration in this manner discovered 
the unfortunate state of the young lady, I felt obliged, in a conscien- 
tious discharge of duty, to tell her the whole truth, which I did in the 
best way I could ; and yet, as may be readily supposed, the know- 
ledge of her situation was accompanied with all the manifestations of 
that violent distress and agitation which might naturally flow from 
such unhappy circumstances. 

The aphrodisiac sense in this lady is very strong, which might well 
be the case where the ovaria are fully developed, even though the 
uterus had never been evolved in her constitution. 

I was deeply impressed myself with the melancholy fate of two 
estimable persons, who would never have placed themselves in so 
unhappy a condition, if by a proper exploration of the parts before 
marriage, the real state of things could have been discovered. The 
case also seems to show how improper it is to permit the rites of mar- 
riage to be solemnized for persons who do not possess all the attri- 
butes properly belonging to the sexes. I do not contend that every 
case of failure to menstruate at the proper season is indicative of the 
necessity for exploration by the touch ; but I think no case of extra- 



132 MENSTRUATION. 

ordinary protraction of an emansio mensium, and especially where 
any question of courtship or marriage is likely to arise, should be al- 
lowed to go on without the acquirement, by the medical adviser, of a 
true and perfect knowledge of the facts as to the organization of the 
parts. 

In the early part of the present year, 1848, I met with another ex- 
ample of similar want of development in a comely young person who 
had been married some three months before. A shallow vaginal cul- 
de-sac at the bottom of well developed external genitalia, mammary 
glands of full size, warm aphrodisiac temperament, and abundant 
hair, showed that all the sexual physical attributes were present, save 
only as to the absence of the uterus — no trace of which could be 
detected by Dr. Pancoast, Professor of Anatomy, by Dr. Jewell, of 
Philadelphia, or by my own careful exploration. No doubts were left 
upon our minds of the complete failure of uterine development. 

The persons interested in this unfortunate situation, though less 
sensitive than those mentioned above, were rendered unhappy by so 
grave a mis-alliance — probably the last consequences it maybe greatly 
to be deplored. How important, then, is it that medical attendants, 
the only persons who can be competent, should be always ready and 
watchful as to the points of duty. 

Not only on account of the risk of fatal mistakes of the kind above 
mentioned, should we be ever attentive to the duty of making accu- 
rate diagnosis, but there are a great many other shoals and quick- 
sands in the track of the young practitioner who fills his sails with the 
prosperous and flattering winds of his earliest successes. 

He would find himself under obedience to a good rule, who should 
firmly resolve not to pronounce an opinion, as to the catamenial dis- 
order, until he has taken measures to form a solid and inexpugnable 
judgment on the case submitted to his inquiry. 

The consultations relative to this class of diseases are very nume- 
rous for a medical man engaged in business. Well, let it be a rule 
to suspect of pregnancy every married woman who complains of 
amenorrhoea. This, though so obviously proper, is a rule often lost 
sight of by the medical practitioner, whence it happens that we en- 
counter, now and then, the ridiculous circumstance of protracted and 
vain attempts to bring on menstruation in married women, who at 
length prove to be pregnant. I have met with many such instances. 

Let every married woman who does not menstruate be, therefore, 
treated as if reasons exist for supposing her to be gravid. If, by the 
lapse of time or by the occurrence of circumstances, a solid convic- 



MENSTRUATION. 133 

tion can be attained that the patient is not gravid, she may be suffi- 
ciently early subjected to a treatment conformable to her wants. 

In like manner, in young unmarried women failing to menstruate, 
yet exhibiting no other evidence of disordered health, there is time 
enough to consider what may be requisite in the treatment. The 
more especially, if we may believe that, which I consider undeni- 
able, namely, such a woman, healthy, vigorous, and in all respects 
enjoying the complacency that can only exist in those that be well, 
does really perform her physiological act of menstruation — to wit, in 
the regular deposit of her germiferous ova; or that pregnancy pre- 
vents the exercise of menstruation. 

It will, perhaps, appear to be almost a rudeness to make this asser- 
tion, and I should not venture to make it in this place, but under 
a sense of the duty I owe the young student, which calls upon me to 
put him early upon his guard. I have so often been nearly deceived 
in instances of this kind, that I am convinced that nothing but a con- 
stant cautiousness has saved me from making the grossest mistakes. 
Many have been the occasions of my being consulted for catamenial 
obstruction, with a design to entrap me into the administration of 
drugs that might remove the difficulty by procuring abortion, but like 
all those who will resolve to adopt the rule which I suggested above, 
I have hitherto escaped so distressing an error of commission. Should 
a female, presenting all the appearances of brilliant health, complain 
of such obstruction, I should be sure to come to one of the conclu- 
sions indicated in the paragraph — viz. : either the ovarian stroma is 
active and regular in the performance of its mensual physiological act, 
or a gravid state prevents the sign of the act from becoming manifest. 



134 AMENORRHEA. 



CHAPTER VII. 



AMENORRHEA. 



If a girl reaches her fifteenth or sixteenth year, and falls into dis- 
ordered health, her catamenia not making their appearance, she is 
commonly presumed to be laboring under amenorrhoea, to which is 
attributed the vicious state of her constitution, and which it is sup- 
posed must be removed, in order to admit of a more perfect play of 
the powers of the economy. Those who have never had the menstrua 
are said to be laboring under emansio mensium, or retention of the 
menses; while those who have already been regulated, but are now 
deprived of it, are said to be affected with suppressio mensium, or 
amenorrhoea. 

There are many causes that may suffice to prevent a young person 
from menstruating w T hen she attains the usual age for it, besides that 
general torpor or slowness of development of which I have already 
spoken. Thus there may be a total absence of the uterus ; or the 
uterus may possess a faulty conformation, as I have already men- 
tioned. The canal of the cervix may be imperforate. The ovaria 
may be wanting. The vagina may be imperfectly developed, or of 
monstrous form. The entrance to it may be closed by adhesive 
inflammation, or by an imperforate hymen, or non-development. 

If the non-appearance, at due time, of the menses should depend 
upon a general deficiency of the vital forces, it would be easy to verify 
the cause, by carefully observing and comparing the play of the great 
functions ; and upon their being found to be free from any special 
disorder, the inference would be strong in favor of a mode of treatment 
calculated to excite and invigorate the whole system; or the prudent 
physician might advise that no treatment should be adopted, but rather 
that confidence ought to be placed in the powers of nature, which, in 
proper time, can overcome disorders of this particular class. But in 
all cases of emansio mensium, it is of the last importance for the 
medical adviser to reflect carefully upon the circumstances of the 
patient before instituting any plan or method of cure. 



AMENORRHEA. 135 

Is it not notorious among the profession that the medical treatment 
of amenorrhea is eminently empirical, unsatisfactory, and unsuc- 
cessful? It must be admitted, that the subject is, in a practical view, 
a very difficult and embarrassing one; nevertheless, I feel much per- 
suaded, that a more considerate and a more rational attention devoted 
to the cases which fall under our notice, would enable us more fre- 
quently to administer relief, without being obliged to resort, as we are 
now, often to every one of the menagoga in succession, and in vain. 

A blister applied to the thorax often cures a pleurisy, upon the 
principle that "pars dolens trahit," or the principle of counter-irrita- 
tion. It is equally true, that any considerable external or internal 
fixed irritation may prevent or counteract the natural tendency of the 
system to produce catamenia. A wet stocking, a draught of cold and 
damp air, produces in the skin a certain condition which frequently 
serves to prevent or arrest the menstrual offices ; a fortiori, therefore, 
some latent disorder of an important viscus or organ, would scarcely 
fail to interrupt, or in some measure trouble, this delicate depurative 
act. Hence, instead of opening the great volume of the Materia 
Medica, and searching under the head of Menagoga for some specific 
means of removing the difficulty, let the medical man carefully study 
the state of the patient's health, endeavoring by repeated inquiries 
to learn the rate of the several great functions, and that of numerous 
minor ones, in order, in their excess or deficiency, to find a cause of 
the amenorrhea, which he will then be able to treat with the reason- 
able methods that a perfect understanding of the case will suggest to 
him. 

It is not to be supposed that if a woman's constitution can be 
brought into healthful play in all other regards, she will be vicious 
or disordered in this instance, of menstruation. I grant that sudden 
arrests or stoppages may take place from slight and perhaps local 
causes ; but I speak now of the instances of rebellious obstructions. 
I wish to impress the idea, not that a woman is unhealthy because 
she fails to menstruate, but rather, that she fails to menstruate be- 
cause she is unhealthy. 

Let us suppose a case. A young woman has her feet wet the day 
preceding that on which she should be regular. She has a rigor, 
succeeded by fever, intense headache, vomiting, pain in the loins and 
hypogastria, &c, all which phenomena are results of the violent re- 
action of the system upon the morbific impression of cold and damp- 
ness. The symptoms frequently appear before the time of the flow, 
and they continue with more or less severity until the show takes 



136 AMENORRHEA. 

place, when they are immediately relieved; or, as is often observed, 
they are first relieved by a venesection or purge, after which the show 
makes its appearance; or they may wholly prevent the menses from 
coming down, and be the first instance of a long series of failures. 
It appears to me to be quite clear that in a major part of such cases 
as I have supposed, a sound philosophy leads us to endeavor to sub- 
due the constitutional disturbance by the proper means for that end, 
so that the patient may recover in order to menstruate, and not that 
she may menstruate in order to recover. 

The treatment of acute cases by venesection, purgatives, warm 
baths, camphor, opium, &c. &c, shows conclusively that the physi- 
cians appreciate the real principles of such practice, and it is therefore 
the more surprising that they are many times, in chronic cases, ob- 
served to abandon reason, and follow the most empirical, crude and 
indigest notions of treatment. 

Of all the great functions, none, I am persuaded, is so intimately 
related to the menstrual affections as that of the circulation. Let its 
condition be fully investigated and understood: is there an improper 
momentum of the blood directed upon other organs ? is it excessive 
without particular determinations? is the movement of the blood en- 
feebled ? does the patient, by exercise or labor, compel the circula- 
tion in the capillaries of the muscles to be sufficiently active and free, 
to obviate the tendency which is thus acquired to the central or visceral 
congestions and engorgements so ordinary in the sedentary and lazy ? 

Inquiries should always be made concerning the state of the hepatic 
functions. Is there a torpid or obstructed portal circulation ? Can 
the whole venous circulation of the chylopoietic viscera, destined at 
last to pass through the portal vein, be vitiated without in some mea- 
sure affecting that of the genitalia ? If the bile is acrid, or weak, or 
deficient, will it not cause disorders of the alimentary canal, that must 
retard or hinder the natural tendency of the vital movements in the 
womb and ovaria ? In such circumstances, attempts made to restore 
the health by forcing medicines, for of such are most of the class 
menagoga, will rather serve to fix and rivet the irritation, than to re- 
move it ; at least, they are generally fruitless. If she be menaced 
with consumption, for example, the woman early loses the catamenia, 
and a pressing demand is made upon the medical attendant for its 
restoration; but rash attempts to effect its return by means of emme- 
nagogues, are quite as apt to bring on hsemoptoe, as the more natural 
discharge which is the object of so great a solicitude. 

The skin has an intimate relation, by sympathy, to the whole of 



AMENORRHEA. • 137 

the mucous system, whether respiratory, digestive, or genito-urinary. 
It cannot be, therefore, too carefully looked to. In amenorrhoea it is, 
for the most part, dry, pale, and not sufficiently elastic. In extreme 
cases it becomes so much altered, so opake, harsh and disagreeable, 
as to attract the attention very particularly. Its chlorotic color gives 
to bad cases of amenorrhoea the title of green sickness, or chlorosis: 
such a state must be inseparable from an engorged and obstructed 
condition of the viscera, which, whenever they are oppressed and 
crushed under the masses of blood imposed upon them, can never 
cease to be the centres of movement for the sanguine as well as nerv- 
ous systems, and thus appropriate the tendencies of fluxion that ought 
to exist towards the uterus. If we recall the blood to its legitimate 
channels, by restoring to the skin its proper energies, in removing the 
visceral obstructions or torpor, the amenorrhoea ceases, and the rate 
of all the functions becomes equalized. Moderate bleeding, local or 
general; purgatives; an emetic; frictions with the flesh brush, or 
with salt, or dry mustard; the warm bath; a blister judiciously 
timed; the wearing of flannel next to the skin; exercise on horse- 
back ; walking, as a regular duty ; dancing, and various gymnastic 
amusements — all these may be safely looked to as means of relief, 
far more to be depended upon than the empirical administration of 
drugs, whose modus operandi is, in general, but darkly suspected, 
and never fully understood. 

The removal of corsets and all tight bandages or dresses, and the 
rigorous prescription of flannels, stockings, shoes, shawls, &c, must 
not be deemed unworthy of the physician's attention, any more than 
the dietetic regulations, which should always correspond to the wants 
of the case for the time being. 

Among the causes of disordered menstruation, we ought not to lose 
sight of the disturbing nature of those deviations by which the womb 
is, so to speak, dislocated and tortured. Both anteversion and retro- 
version, as well as various degrees of prolapsion, bring upon the ute- 
rus states of disordered action well calculated to interfere with the 
normal play of its functions as to menstruation. 

After having subdued or mitigated the local disorders, and the con- 
stitutional disturbance arising from them, if the sanguine apparatus 
of the womb still fails to act properly, in yielding the catamenial dis- 
charge, the time is arrived for resorting to the emmenagogue articles. 

It is a general complaint, that we have, as yet, no good emmena- 
gogues ; and that the uncertainty in regard to their operation, is as 
great as to that of the diuretics. It would seem, indeed, that the mate- 



138 AMENORRHEA. 

ria medica includes no article that exercises an immediate or specific 
action upon the womb, if we except the secale cornutum ; and even 
of its powers much question is still made, notwithstanding a great 
deal of experience already had of its employment. 

Among the articles of the materia medica, those are most to be 
relied upon, as emmenagogues, which exert an indirect influence on 
the womb by sympathy with the bladder or rectum : such are cantha- 
rides and aloes, by the administration of either of which, we have it 
always in our power to produce a very considerable excitement in the 
pelvic viscera. The action of the womb upon the rectum and bladder 
is well known to be very decided: tenesmus, dysuria, and other 
graver affections accompany and make manifest some of the uterine 
diseases. So, too, when the bladder is highly irritated by cantharides, 
or the rectum by drastics, the uterus partakes of the excitation or in- 
creased vital action. In fact, it is found that aloetics and cantharides 
are among the most successful of the emmenagogues. I am convinced 
that these articles are ordinarily administered without sufficient bold- 
ness, and that they ought to be freely employed whenever they are 
indicated. 

The operation of these medicines upon the womb may be greatly 
promoted by the occasional employment of the hip-bath, the pedilu- 
vium with infusion of mustard, and full draughts of infusion of some 
aromatic herb, especially the pulegium. The tincture of black helle- 
bore, in doses of a teaspoonful, has often been in my hands followed 
by a restoration of the menstrua. The dose should be repeated every 
six or eight hours, being followed by the use of an aromatic infusion. 
The volatile tincture of guaiacum ; the decoctions of seneca, of madder, 
of serpentaria ; the tinctures of castor, of aloes and myrrh, and the 
chalybeate preparations, are all justly chargeable with the great un- 
certainty as to their operations of which Dr. Cullen so loudly com- 
plains. They undoubtedly do succeed now and then, when happily 
timed, and furnish, at least, an armamentarium medicum, from which 
the enlightened and judicious practitioner can select the means of 
combating the principal disorder, after he shall have first mastered 
the constitutional disturbances, which, in general, offer the most con- 
siderable portion of the resistance he has to contend with. 

It is very true that a case of amenorrhoea may depend upon a faulty 
life-force in the womb itself, which, from a sluggish condition of its 
circulation, depending upon some feebleness of its system of nerves, 
shall fail to perceive and obey the influences that should legitimately 
act upon it, in coincidence with the periodical exacerbation of the 



AMENORRHEA. 139 

ovarian life-force. In such an instance, whatever might seem to 
quicken the activity of the life of the child-bearing organ itself, might 
serve as a positive emmenagogue. 

On the other hand, as the uterus is eminently fibrous, it is the fre- 
quent seat of rheumatic disease, which, occupying it wholly, may 
have power to prevent it from performing the act of the menstrual 
elimination. Certainly, rheumatism is among the commonest of the 
disorders of the womb, and when it acquires a chronical character, it 
scarcely fails to carry disorder into the periodical offices of the organ. 

Again, the uterus is subject to engorgement, which is not uncom- 
monly connected with some deviation of its place or attitude. Such 
deviations are scarcely consistent with a healthful power of the womb, 
whose nervous and circulatory operations suffer in consequence, — 
especially in the instances in which the cervix uteri becomes bent, 
as is frequently the case. In all these forms, the medical treatment 
should be preceded by a surgical method — as the uterus would not 
be likely to recover its health until the organ should have been re- 
lieved of its false place or attitude. 

In my opinion, though the causes now enumerated are not rarely 
to be regarded as lying at the foundation of amenorrhceal affections, 
the major part of the examples are dependent upon a cessation of the 
force by which ovarian vesicles are evolved and matured. Patients 
suffering with chronical maladies, attended with protracted amenor- 
rhcea, exhibit, in the ovarian stroma, no vestiges of the Graafian vesi- 
cles. I lately examined the ovaria of a girl who died after some 
eighteen months of severe chronical ailments, during which she did 
not menstruate. Those ailments had no connection at all with any 
state of the reproductive organs, yet upon carefully examining the 
ovarian stroma of both the ovaries, it was found to be a compact, 
whitish stroma, very similar to that which we observe in women long 
past the change of life. No trace of the ovarian vesicle existed in 
either of them. 

It is clear from this dissection that the lady could not possibly have 
menstruated, if the doctrine be true — and further, that, in case her 
health could have been restored as to her chronic malady, many days, 
weeks or months must have elapsed, before the ovarian stroma could 
have developed the vesicles, matured and discharged them, so as to 
give rise to the sanguineous sign of the mensual act. It is apposite, 
further, to ask, in this place, what powers are possessed by the mena- 
goga, capable of speedily restoring the discharge, in such cases of 
amenorrhcea. 



140 AMENORRHEA. 

This subject brings me to the consideration of certain articles as 
therapeutical agents in the disorders now in question, and I shall pre- 
sent, as concisely as possible, the opinions I have long entertained, 
and elsewhere expressed. 

The human female does not menstruate until full puberty. The 
woman ceases to menstruate at forty-five years of age. She men- 
struates during thirty years of her life. She required fifteen years of 
development to acquire the power, and she survives the exhaustion of 
it some twenty years, less or more. She possessed the same anato- 
mical character both before her puberty and after the change of life 
that she had during the highest vigor of the menstrual forces. In- 
deed, it is not rare to meet with persons who, being robust during 
childhood and in approaching to puberty, lose their strength and vi- 
gor of health as soon as they become regular and bear children, in 
order to acquire strong health again, upon the completion of the 
change of life. 

What is it that a female acquires at puberty, and what is it that 
she loses at the change of life ? which, while she possessed it, enabled 
her to menstruate with precise regularity, or perform all the functions 
relative to the mensual forces? The anatomist can discern nothing 
beyond certain differences in the ovaries. 

It appears to me that she has acquired a peculiar surplus of biotic 
force — a complement of the somatic powers, designed, like the com- 
plementary powers of plants, to enable them to effect the great object 
of extension and conservation of genera — a force not required in the 
ordinary occurrences of a mortal life ; and, therefore, vouchsafed to 
them only as special and extraordinary powers adapted to the attain- 
ment of a special and extraordinary end. 

Such powers could only be intermittent and paroxysmal — they 
could be periodical — and in nature we find them not only paroxysmal, 
but very exactly periodical, in all the classes, and, indeed, in all the 
departments of organic existences. In his Physio-Philosophy, Oken 
says — " The blood is the fluid body; and the body is the fixed and 
rigid blood." These are the words of Prof. Oken, who, in using 
them, has but reiterated the sayings of his predecessors. The saying 
is a true one. And if so, then it follows that the body depends essen- 
tially for its constitution on the blood. If the blood be perfect, the 
body is likely to be so, and vice versa. The ordinary status of the 
body depending upon the crasis of the blood, how indispensable is a 
proper crasis of it to the execution of those paroxysmal, intermittent, 



AMENORRHEA. 141 

periodical special acts, whose nature and sources we are con- 
sidering. 

But the blood, out of which the whole body is made and main- 
tained in its status sanitatis ! Whence comes this blood, this genera- 
tion of the body ? 

I have neither purpose nor time to enter at length into an examina- 
tion of the principles of the hsematosis. Such an essay requires not 
a few pages, but a volume ; but without entering at large on the sub- 
ject, I may, in hopes of explaining myself, state a few particulars for 
that end. 

1. The blood is daily renewed by means of the alible matter 
digested, in the stomach and bowels, and absorbed by the lacteal ab- 
sorbents, by which it is transferred to the blood-vessels. 

2. The whole of the blood is contained in the heart, the arteries, 
the capillaries, the erectile tissue, and the veins. 

3. The only tissue that the blood touches is the endangium, which 
is the lining or interior membrane of all blood-vessels. In the vis- 
cera — in all the organs, indeed — it is probable that the ultimate 
ramuscle of a vessel consists solely of endangium, the stronger coats 
being unnecessary in the last distributions. The endangium, to use 
the idea of Prof. Burdach, separates the blood from the body, as the 
scarf-skin separates the body from the external world. The endan- 
gium is the delimitory membrane of the blood. The blood perishes, 
or changes very soon, almost immediately after it escapes from within 
the endangia. It is converted — bio-trophically, or it is coagulated, or 
it becomes dissolved, or it ceases to be blood upon leaving the cavity 
of the endangium. 

4. Notwithstanding the chyle — particularly chyle taken from the 
upper end of the thoracic duct — contains vesicles or globules, or cor- 
puscles, that are of a reddish hue, and that are the results of the 
earliest morphological powers of the hsematosis, it is not proper to 
regard these corpuscles as blood. 

5. Soon after the chyle is poured into the cavity of the endangium, 
and becomes exposed to the influences of the oxygen in the lungs, 
it acquires the character of perfect blood. 

6. It is not to the oxygen alone that it is indebted for this farther 
morphological development. 

7. Contact with the endangium is essential to that development, 
since the blood loses its physical character as soon as it ceases from 
that contact. The endangium contains the force that 
makes the blood. This proposition, which I put forth in my 



142 AMENORRHEA. 

Letters to the Class, has been denied. I reiterate it here — and I ask 
what violence is done to probability in this doctrine, — seeing it is 
universally admitted that the power of a cell — a far more simple and 
elementary body — is so great that it can, out of the alible cytoblastem 
in which it exists, produce by its metabolic and plastic energy, car- 
tilage, ligament, skin, muscle, accisiferous viscera, nerve, and, indeed, 
all the solids of the body ? If the to wtufiauxov xat to it-kwtixov really 
appertain to the simple tissues of cells, may we not concede a higher 
power to the elementary structure, which we call endangium ? The 
cell-power is a power of pressure and contact, not a power of perco- 
lation or endosmose or exosmose merely. 

8. The endangium is the blood-membrane. When it is healthy, 
the blood is so — when it is diseased, the blood becomes diseased. 
The health of the endangium is as essential to a normal haematosis as 
that of the gastro-intestinal mucous membrane is to the health of the 
digestive forces. In diseases of the endocardium, the functions of the 
heart are modified, but, the endocardium is the endangic membrane 
of the heart. Similar affections of the endangium ranging throughout 
extensive portions of the sanguiferous system, derange the blood-ves- 
sels and the blood. 

9. Simple diminution of the life-force in the endangium, produces 
the idiopathic forms of ansemia, in which the solid constituents of the 
blood become lessened in quantity, w T hile the aqueous constituent in- 
creases in quantity. 

10. One thousand grains of healthy blood ought to contain seven 
hundred and ninety grains of water. In anaemia a thousand grains 
may contain eight hundred and fifty grains of water — or even more. 
Such a state of the blood is anaemia. 

11. Plethora is a contrary state, one in which the watery propor- 
tion is lessened, and the solid constituents augmented. 

12. The endangium is the regulator of these proportions — when its 
powers are either lessened or exaggerated, the crasis is changed. 

13. The nervous mass, acted on by oxygen, gives out the nerve- 
force, the biotic force, the life-force. It does not extricate or give out 
that force under any other exciter or influence. 

14. The arterial blood conveys oxygen, which it imparts to the 
nervous mass. Perfect blood conveys the due amount of oxygen to 
develop a perfect innervative force. Imperfect blood cannot convey 
a due amount of oxygen — whence the innervations produced by it 
are inevitably imperfect. 

15. The health, activity and power of all the organs, are but the 



AMENORRHEA. 143 

exact expression of their innervation. Under circumstances of imper- 
fect blood in the endangium, their health, activity and power become 
deranged. 

In these fifteen propositions, I have set forth the opinions I have 
long held as to the influence of states of the endangium upon the 
health. I am, perhaps, imprudent to put them forth in this manner, 
and without the support of many facts and many arguments that I 
deem confirmatory of them. I prefer, however, to submit them to the 
reader in all their nakedness, rather than not to present them for his 
examination. I hope that in any event, they may serve me to elucidate 
the rationale I am about to state as to the amenorrhceal affections 
which are still under consideration. 

I have said that the reproductive is a complementary force, and 
that menstruation is a sign of the active state of that force. 

The blood of an anaemical girl is incapable of developing her innerv- 
ative force in sufficient amount for the regular operation of the ordi- 
nary functions. She will, therefore, scarcely produce nervous force 
sufficient to execute both the special and the complemental offices of 
her life. 

The amenorrhceal girl is generally anaemical. To cure her anaemia 
is to re-establish her dominion over both the special and the comple- 
mental, powers and offices of the system. 

No attempt should be made to bring on menstruation in order to 
the cure of the anaemia — but, mutatis mutandis, the anaemia should 
be cured in order that her blood, fully and thoroughly oxygeniferous, 
may enable her nervous mass to extricate the biotic force in some, 
equal to the demands of the general, as well as the special or comple- 
mental, wants of the economy. 

The curative indications for such ends consist in the use of drugs, 
frictions, baths, exercise, dress, diet, and medicines — as well as the 
psychiatric recommendations that may be apposite for the cases. 

Drugs. — Aperients are, for the most part, indispensable, and they 
may well consist of a basis of aloes, or other resinous cathartics, in 
combination with rhubarb or extract of colocynth — and upon occa- 
sions, of mercury. 

The celebrated Hooper's pill, which is familiarly known by every 
mother in the land, is composed chiefly of aloes. 

The Dinner-pill, or Lady Webster's pill, is also aperient on account 
of the aloes combined with it. 

In some of the samples of amenorrhoea, which, while they depend 
mainly upon a want of vigor in the blood, may derive a part of their 



144 AMENORRHEA. 

rebelliousness from unhealthy states of the circulation and innervations 
of the pelvic viscera, a useful resource is to be found in the compound 
powder of Jalap. Doses, consisting of twenty grains of Jalap, forty 
grains of cream of tartar, and six drops of oil of anise-seed, may be 
given every alternate morning with considerable advantage. I have 
sometimes directed my patients to procure half a dozen packages, 
each containing such a dose, and to use one of them every other day, 
until the whole of them should be taken. 

When an idea is entertained that the hepatic secretions are im- 
paired, under a vicious state of the putal circulation, a very proper 
alterative will be obtained in the exhibition of six grains of blue-pill, 
fifteen grains of extract of taraxacum, and ten grains of soda, sus- 
pended with a dram of gum Arabic, or an ounce of distilled mint or 
cinnamon-water. Such a dose should be followed by an aperient 
dose of magnesia, oil, senna, or salts. 

Tonics. — The most available tonic is iron. 

Iron appears to possess a peculiar power to modify the rate of the 
hsematosis. Certainly, one might in vain endeavor to remove certain 
cases of ansemia by the aid of quinine, the various vegetable tonics, 
and the mineral tonics, with the same rapidity and certainty as with 
the ferruginous medicines. I believe that common experience teaches 
the truth of the above proposition. 

I know not what is the rationale of the almost specific power of the 
martial preparations in anaemical disorders, and I am unwilling to enter 
upon the question, whether the iron enters into direct combination with 
the blood, to render it more powerful and more noble by its union with 
it — or whether it acts as a direct tonic for the solids of the economy, 
thus empowering her to exert a greater energy of potentialization upon 
the cell-life of the blood-corpuscles. I am not capable of settling 
this question, and I suppose no other man is able to do so — nor is 
it vitally important that it should be settled. But I deem that nothing 
is better or more clearly established, as a therapeutical maxim, in my 
mind, than this, namely, that an ansemical girl, who labors under no 
other malady, is cured of her ansemia in about sixteen days, by the 
proper use of iron. 

There are a great many martial preparations. 

Vallet's mass, which is the same article as the pil. ferri carb. of 
the U. S. Pharmacopoeia, is a very serviceable article, and the purple 
precipitated carbonate of iron is also an article of great power, but 
not unapt to prove irritating to the stomach, especially in the extrava- 
gant doses commonly allowed — as a teaspoonful twice or thrice a-day. 



AMENORRHEA. 145 

The pills of Dr. Blaud, of Caux, have also acquired a great celebrity 
for their emmenagogue power. They consist of carbonate of iron, 
combined with sulphate of potash. 

The muriatic tincture of iron has likewise been much employed — 
as has also the combination of iodine with iron. 

Now, in the exhibition of ferruginous medicines, it is understood 
that the iron is the therapeutical agent on which reliance is placed — 
and there seems to me little advantage in exhibiting it in combination 
with any particular acid, since it is to be supposed that such com- 
binations are immediately dissolved and new relations established 
with the metallic base, in the stomach. Hence, I in theory greatly 
prefer to administer the article in its metallic form, and thanks to the 
ingenuity of Messrs. Quevenne and Miquelard, of La Pitie hospital, 
at Paris, we are favored with an impalpable powder of iron, that is 
prompt to enter into chemical union with the acids of the digestive 
canal. 

This beautiful agent, which is produced by passing a current of 
hydrogen over peroxide of iron heated to redness in a porcelain tube, 
is a microscopic powder of iron — since the hydrogen, having united 
with the oxygen of the peroxide to form water, has left the iron pure 
and uncombined. It is prepared at Paris, by M. Quesnesville, the 
successor of Messrs. Pelletier and Caventou, and sold by the import- 
ers and apothecaries in this country. 

My own custom is, to exhibit it in the form of pills weighing two 
grains, and I habitually direct the patient to take one of the pills very 
soon after each daily meal: if swallowed while the stomach is engaged 
in the act of digestion, it does not occasion any sensation ; and it is 
present and in readiness for any salifying acid that happens to result 
during the chymification of the food. 

It is both inodorous and tasteless, and may be used without danger 
during an indefinite series of days, or weeks, or months. 

No doubt rests upon my mind that it is the most powerful, safest 
and least disagreeable tonic drug that the therapeutist can pre- 
scribe for the amenorrhceas depending upon a principle of anaemia — 
the most ordinary principle of those maladies. I ought to add, that 
my attention was attracted to it by M. Raciborski's work sur la Ponte 
Periodique, and that it is to him I am first indebted for the practical 
advantages I have received from this medicine. 

In addition to the doses of iron used as above, it is necessary for 
the patient to observe certain rules as to the action of the bowels, 
which cannot be expected under the imperfect and irregular extrica- 
10 



146 AMT.XO&RHCEA. 

'i:n :f hictic force of the anaemical girl to be exact and orderly as for 
persons in health. 

Medicines, of which the basis is aloes, are particularly adapted to 
such cases. The elixir proprietatis ; the pill of aloes and rhubarb; 
the pill called Lady Webster's or English dinner pill ; the tinctura 
sacra, and a variety of such formulas, afford the opportunity Foi select- 
ing such preparations as may seem best suited to the existing indi- 
cations. 

Acescent food is the cause of much digestive distress. The aces- 
cent vegetables and fruits ought, therefore, to be eschewed, and, 
indeed, a considerable proportion of the food should be taken from 
the animal kingdom. Brown meats and game are preferable. A 
roast chicken, or roast beef or mutton, is preferable to other kinds 
of market provision, and it is, when practicable, useful to cause the 
patient to take a portion of meat at breakfast and tea, as well as at 
dinner. 

Hot drinks, as coffee, tea, and chocolate, or cocoa, are debilitating to 

the already feeble powers of the stomach. When such articles ought 

not to be allowed, the patient can take claret and water, with meat 

and bread, and butter and eggs, for the breakfast, often with signal 

advantage. But the wine should be pure and unadulterated with 

brandy, which is so commonly added to every cask of claret sent 

I ] the I nited States for sale. Good Bordeaux wine, non-f relate, that 

not brandied, makes an admirable substitute for boiling tea, coffee, 

and chocolate, which, though they may not sensibly injure persons 

in str::.g health, are yet surely unsuitable to the feeble and attenu- 

ited female. 

There is no health without exercise and light. The patient should 

much in the open air, exposed to solar light, when not too intense. 

See sh: :i:l r-inf:rce t'ne rowers of the circulation by means of exer- 

r. The best exercise is active, not passive exercise. But I dare 

not devote these pages to an extended discussion oi this subject. I 

e in my seventh and twenty-seventh •• Letters to the Class," pretty 

:.-.-:.:'.-■ :~i my views on the topic, and refer the Student to those 

Letters. 



PREGNANCY. 147 



CHAPTER VIII 



PREGNANCY. 



Pregnancy.— The subject of pregnancy is one that is worthy of the 
most careful study by those who intend to devote themselves to the 
pursuits of Obstetricy, and indeed, it merits the attention of all per- 
sons desirous to become acquainted with those miraculous powers 
and actions of the living body, that result in forming and perfecting 
a human being, the crowning work of the Deity, who thus ordains 
man to come forth from the darkness of non-entity, to shine upon the 
stage of the world, and there act his part for immortality. 

There have appeared a great many speculations and theories upon 
the subject of Generation: yet it is true that, however ingenious or 
inventive their authors, or however eloquent or argumentative in 
urging the adoption of their peculiar views, there still remains a terra 
incognita of Embryogeny, which human sagacity, perseverance and 
toil have never been able to explore ; and which seems purposely set 
beyond the reach of the utmost stretch of human wisdom or learning. 

It must ever, w^e should think, remain impossible for man to com- 
prehend the secret mysteries of those proximate causes, by the force 
of which, a non-existent, or formless being is drawn forth of the dark 
stream of time, and launched out on the boundless ocean of eternity; 
made partaker of a prospective immortality ; charged with the burden 
of responsibilities to God and his fellow creatures ; and bound by nu- 
merous liens to the physical world, of which he has also become a 
part by the very fact of his entrance into a moral state. Such a sub- 
ject, nevertheless, cannot fail to prove interesting to the Medical 
Student, whether he approaches it in view of its physiological con- 
nections, or whether he wishes to investigate it as a psychological 
inquiry of the utmost importance in any system of moral philosophy. 
What subject indeed could be more replete with interest, than one 
which pretends or seeks to explain all the changes that are experienced 
by the embryo, from its first discoverable estate as a drop of pellucid 



148 PREGNANCY. 

lymph, up to the time when it comes forth into the world endowed 
with all the powers that are appropriate to a healthy, full grown foetus 
at term! Such a study involves a comparison of its organs with those 
of the adult animal, and a complete history of their development and 
growth ; and it ought also to comprise an account of the accidents and 
diseases to which it is exposed or liable, with a full detail of all the 
peculiarities of the ovum and its several parts, and a comparison of 
them with the similar parts in various animals. The subject com- 
prises, therefore, a vast field of physiology, which might be profitably 
explored by the curious Student ; but the limits of this work are too 
confined to admit of it being treated of at length on this occasion. 

If, as has been eloquently said, the springing up of a blade of grass 
from the bosom of the earth is calculated to fill the mind with wonder 
and amazement, what far more vivid impressions of the miracles of 
power are likely to be made upon those who contemplate the unfold- 
ing of those organs and faculties, by means of which man learns not 
only to know and acknowledge his Maker, but to render himself, as 
it were, a still more fitting image of Him, by the cultivation of the 
faculties that have justly given him the title of the lord of creation! 

In addition to the interest as a merely philosophical study with 
which our subject is clothed, it appears to me indispensable that the 
Medical Student should make himself acquainted with it, as taught in 
the present era, and that he should aim to obtain a thorough know- 
ledge of the subject, a knowledge supposed to fit him for the con- 
duct of cases in midwifery. But, let him consider whether, in 
aiming at this so called practical knowledge, he is not also called 
upon to make himself master of all those scholarly acquisitions 
which alone can shed a light of revelation upon the dark and doubt- 
ful questions that in his practice he must not only solve, but instantly 
solve. To know that a pregnant woman has a child in the womb, 
and to learn by rote something of the presentations, positions, and 
manoeuvres relative to the midwifery operation, is but a vulgar know- 
ledge, common to old women and to physicians who confine them- 
selves to the study of text-books and the unrecorded and misunder- 
stood experience of their own clinical operations. The Student ought 
to study the subject not merely as a midwifery qualification, but as 
an Obstetric Science, the possession of which places him in the fore 
front of his professional rank. 

Pregnancy is the development of an embryo or foetus 
in the womb. 

An account of pregnancy comprises a relation of all the changes 



PREGNANCY. 149 

that take place in the reproductive organs, and in the whole economy 
of the female, from conception to the end of the puerperal state, as well 
as a history of the development of the foetus. 

It is proper, however, for convenience sake, to separate the account 
of pregnancy and embryogeny from that of parturition, which in itself 
presents a great and imposing subject of study. 

Inasmuch as there are, besides natural or healthful pregnancies, 
cases to be met with of morbid or preternatural pregnancies, the 
latter merit a proper share of consideration. Hence, we ought to 
inquire not only into the physiological, but into the pathological con- 
ditions that are brought about by pregnancy, and learn the seat, nature, 
causes, signs and cure of many troublesome disorders and dangerous 
accidents that overtake the gravid woman. 

Fecundation. — In order that a woman may become pregnant, it 
is necessary that a germ, matured in one of the ovaries, should be ex- 
pelled from its Graafian follicle, and then fecundated by the encounter 
of it with the male sexual element, the sperm or seed. I have already 
shown that the germ is contained within an ovum or egg ; which the 
woman, like all other reproductive animals, matures and spontaneously 
discharges at regular periods. 

I shall by no means pretend to show what is the nature of the mu- 
tual influences of the seed and the ovum, or which it is of the two that 
in this generative encounter furnishes the nucleole of the new entity 
about to start on the career of development. These are mysteries 
beyond human ken, and likely ever so to remain. It is in the mean 
time unquestionable that the concurrence of two different systems of 
genital organs is indispensable ; that one of them must be female, 
ovaric, or germiferous, and the other male, yielding spermzoons and 
a fluid of peculiar properties. Neither the female nor the male is 
endowed with the independent power of reproduction. It is usually 
admitted that the female yields the germ, and the male a material 
which, upon some combination or contact with the germ, imparts to 
it the power to grow or augment in a certain ratio, and only in given 
and rigorously predetermined forms. 

Without desiring to call in question this opinion as to the germife- 
rous nature of the female, an opinion which I cannot but adopt, I may 
avail myself of the occasion to advert to the opinion set forth by M. 
Schleiden, that the developing matter of the embryo plant — its 
primal soli d — is contributed by the male organ of the vegetable. 
Mr. S. shows that the pollen tube is a series of cells propagated from 



150 PREGNANCY. 

the pollen grain — that the pollen tube shoots its terminal cell into the 
ovary of the plant, and that cell, making use of the cytoblastema, the 
medium in which it is now placed, begins the career of the new 
vegetable, plant, or tree. 

In this view, the terminal cell of the pollen tube is the germ, and 
the anther which yields the pollen grain is a female, not a male organ. 
For that which produces the germ is female. But, even if M. 
Schleiden is correct in his views, the dogma is not overthrown — na- 
turalists have merely mistaken the sexual characters of plants, calling 
those female that are truly male, and vice versa. 

At the present day, it is not doubted that the woman produces the 
germ by the force of her ovarian stroma ; yet it is not long ago that 
it was contended that a zoosperm, or spermatic animalcule conveyed 
to the surface of the ovary, and entering in at a pore, finds a nidus 
or matrix for its early morphological operations, being thus the start- 
ing point of the embryogenic processes. 

Little doubt exists as to the cell-nature of the ovulum of the mam- 
mals — and there is some reason to believe in the cell-nature of the 
spermzoon. If they be equally cells, which hath the pre-eminence, or 
which is the true germ? and where is the philosopher that can, with 
absolute assurance, declare which of these cells is the primal solid 
in the generic or fecundative processes ? 

I freely acknowledge my own ignorance of the essential nature of 
fecundation. 

Fecundation is not conception — a woman may have within her 
organs a fecundated ovulum, without having conceived. 

Conception. — A fecundated ovulum entering into the womb 
through the Fallopian tube, and falling without delay into the vagina, 
may be destroyed or lost before conception can take place. It may 
be washed away in a torrent of blood, or carried off amidst a quantity 
of mucus. 

An ovum may suffer the encounter with the male element even in 
the infundibulum or fimbria of the tube, and falling out into the cavity 
of the pelvis or belly, be wholly lost from not making its attachment 
to the serous surface on which it has fallen. 

Conception is the fixation of a fecundated ovum upon the living 
surface of the mother ; it is the formation of an attachment to or union 
with the womb, the tube, &c, of the mother. This is conception, 
viz., the fixation of a fecundated ovum. If a conception 
take place in the womb, it is pregnancy — if out of the womb, it is 



PREGNANCY. 151 

extra-uterine pregnancy — in the Fallopian tube, tubal pregnancy — 
in the ovarium, ovaric pregnancy — in the pelvis or belly, abdominal 
or ventral pregnancy — if it occur in the substance of the wall of the 
womb, it is called interstitial pregnancy. 

Commencement of pregnancy. — Pregnancy ordinarily begins soon 
after the disappearance of a periodical effusion of the menstrua. 

Several days, probably, always elapse betwixt the act of fecunda- 
tion and that of conception. The ovum, in the mean time, under the 
power of endosmose is augmenting in volume and undergoing import- 
ant changes in the arrangement and mixt of its constituent ele- 
ments ; changes that are requisite to fit it for the higher act of forming 
its attachment to the mother. 

It is not precisely known how many days ordinarily elapse between 
the end of the process of ovulation and fecundation, and that of con- 
ception. M. Velpeau seems to entertain doubts as to the four ova he 
describes at page 25 of his Embryologie, and which were from eight 
to twelve days old. It is not known how long they had been in the 
womb before their expulsion. Probably, Sir Everard Home's speci- 
men, described in the Lond. Phil. Trans., was a human embryo of 
seven days. 

The facts seem to concur in proving that shortly after the act of 
fecundation the conception takes place ; but it is probable that the 
time is various. 

As menstruation coincides with the periodical act of ovulation, and 
as the sexual embrace is attended with the orgasm whether gravidity 
follows it or not, there is great reason to suspect that the coitus of the 
sexes is frequently followed by fecundation of ova that are subse- 
quently lost by effluxion, and it is to the last degree improbable that 
every fecundated ovum shall be able to effect its mesenteric attach- 
ment or fixation. 

Fecundation and conception can take place only after the dehiscence 
and discharge of the Graafian follicle, whose ovulum, without the 
aphrodisiac orgasm, must necessarily be lost. 

It is not known how long after the close of a menstruation, the ovum 
continues fit for and liable to fecundation. Our researches, which 
clearly prove that an ovum is discharged with each menstrual period, 
have not revealed to us the date of the dehiscence and discharge. I 
am confident that the nearer to the close of the menstrua, the more 
probable is the fecundative result of a congress of the sexes. I have 
one uterus, taken from a woman who died while menstruating, in 
which the dehiscence of the follicle and the escape of the ovum were 



152 PREGNANCY. 

complete ; so that, in this instance I may venture to suppose that a 
fecundation would be more probable, the sooner the encounter of the 
elements after the close of the menstrua. Perhaps some women go 
through the whole menstrual hemorrhage before the discharge of the 
ovum from the ovarian ovisac. If. Pouchet thinks, that the egg 
retains its susceptibility to the male excitant ibr at least twelve days 
; ftei the ovulation. 

It is quite certain that it does retain its susceptibility for eight 
days; for, certain Jewish women, who remain under obedience to their 
law, neve: admit of the embrace until eight days have passed since the 
show of their uncleanness has disappeared. Other Jews construe 
the command as forbidding any intercourse until eight days after the 
first manifestation of the effusion. 

To this effect I have been repeatedly informed by Jewish females, 
who had no ostensible motives to mislead me ; so that, I find a great 
religious sect to prove that fecundation of the ovulum is possible eight 
days at least subsequent to the drying up of the catamenia, which is 
probably more than eight days after the escape of the ovarian yelk, since 
I have never observed the uterus of one dying soon after the catame- 
nia in which the empty bloody crypt of the egglet was not visible. 

Amidst the doubt and uncertainty that rest upon the subject, it 
must be regarded as scarcely possible to set a fixed term. Hippo- 
crates and Galen, and most medical men, as well as most women, 
since them, believe that the sooner the sexual congress follows the men- 
struation, the more liable is the woman to conceive. It was, if this 
notion be true, a singular policy of the Jewish legislator, that pro- 
nounced such deadly reprobation upon all violators oi the law of 
women's cleanness; and it seems to me a subject of surprise that 
the daughters of Abraham should, to this day, obey a custom calcu- 
lated to obviate the greatest possible productiveness of their nation. 
The number of the Jews at the date of the expatriation under the 
reign of Vespasian and Titus, was about 5,000,000 souls. There is 
reason to think that it has remained nearly stationary since the over- 
turns : f their city by Titos. If ever the curious law of cleanness of 
women be abrogated as to the Jewish wives, would the augmented 
chances of fecundation cause the sons of Abraham to become as the 
stars of the firmament, and the sands on the sea shore for number? Is 
it the operation of this ancient law that has kept the population of the 
Jewish people down, through so many centuries, to one even tenor 
of about 5,000,000 souls: 

I presume that in the present state of our knowledge, there is no 
one who can inform us at what period of the menstrual hyperemia, 



PREGNANCY. 1 53 

the dehiscence of the Graafian capsule usually takes place. I repeat 
that I have not met with any specimen of ovary taken from an indi- 
vidual dying during or soon after the monthly flow, in which the ova- 
rian capsule was not already ruptured, and the egg escaped. The 
uterus and ovaries of a young woman who died suddenly, while men- 
struating, pleno rivo, is in my collection. The bloody pore and empty 
crypt showed that the ovulum, in that case, had escaped early in the 
menstruation. 

It is probable that the ovulation may in some women shortly pre- 
cede, while in the majority it absolutely coincides, in point of time, 
with the first appearances of the hemorrhage. As to the impression 
still entertained by some reputable authors, that the discharge of the 
ovule depends upon the aphrodisiac orgasm, it is too unreasonable an 
hypothesis; too unreasonable, I say, because, the dehiscence being the 
effect of absorptive power, and not of a lacerative or vulnerative force, 
it is idle to attribute to a momentary orgasm, which perhaps has no 
direct influence on the ovaries, a result that requires many days of 
the slow operation of the absorbents of the ovarium. The regularity 
of the ovulative paroxysm is as great in the virgin as in the married 
woman ; and is equally regular, moreover, in the vegetable as in the 
animal kingdom. 

It is much to be desired that careful observations, made as to the 
state of the ovaries in persons dying just before, pending, or soon 
after, the close of the monthly flow, should be laid before the profession 
in order that more accurate notions may be had upon the subject. 

As to the precise place at which the encounter of the sexual ele- 
ments takes place, we do know that it may, and sometimes does, 
occur in the Fallopian tube; and we have certain proof of it in all the 
cases of tubal pregnancy, which are but too numerous in the records 
of Medicine. Possibly it may likewise occur within the womb itself; 
and it may be hereafter ascertained that the instances of placenta 
prsevia are the results of a late fecundation, which admits of the 
fixation of the product upon the os uteri internum. 

The examples of ventral or abdominal pregnancy ought not to be 
taken as proof of an encounter of the male and female elements within 
the peritoneal sac. It is more reasonable to suppose that the encounter 
having taken place in the fimbria, the fecundated ovule, after falling 
out of the grasp of the infundibulum, has made its mesenteric attach- 
ment to some point of the peritoneum upon which it has rested. 

As to ovarian pregnancies, I cannot deem them possible, except 
under the following circumstances. Both Bischoffand Martin Barry 



154 



PREGNANCY. 



have found the zoosperm upon the surface of the ovary in animals 
killed immediately post coitum: this is sufficient proof that the prolific 
semen had been transported by the tube or cornu to the fimbria, whose 
grasp of the ovarium had deposited the zoosperms upon the ovarian 
indusium. If we suppose this transfer to be effected at the moment 
of the appearance, in the opened hila, of a mature ovule, it is clear .the 
generative encounter would here take place, and the act of fecundation 
become complete. Upon some change of posture of the woman the 
further escape of the fecundated ovule might be prevented, the pore 
being stopped by the pressure of a fold of broad ligament, a loop of 
intestine, or other obstructing cause ; and thus the fecundated germ, 
imprisoned within its cell, might commence its career of development, 
making the ancient follicle, which produced it, become its matrix or 
succedaneous womb, up to the time at which it must inevitably burst. 
I am compelled to adopt this hypothesis; for I can by no means con- 
ceive that fecundation of a germ contained within an unopened Graafian 
follicle can possibly take place, as I fully adopt and truly believe Mr. 
Pouchet's doctrine as to the spontaneous discharge of the ovulum pre- 
viously to the fecundation. I cannot believe that the male seed enters 
into the ovisac, through not the peritoneum only, but through the 
albuginea and the concentric coats of the ovisac. 



Fig. 52. 



Decidua. — When pregnancy takes place, the womb is provided 
with a lining or coat, called the decidua or caduca. This caduca has 
been represented as a membrane, which is excreted by the uterus, as 
a means of securing the product of the conception, and affords to it 
a nidus in which to imbibe the earliest elements or pabulum of its 
growth. 

For a long time past it has been generally supposed that the 
womb, coincidently with the fecundative 
era, throws out a viscous excretion from 
its inner walls, so as to line or plaster the 
whole surface with the viscid matter. The 
cut is designed to show the manner in which 
this occurs. The dark, thick outlines repre- 
sent the womb already somewhat expanded 
by the growing ovum, a is the canal of 
the neck of the womb, b is the orifice of 
the left Fallopian tube, whose fellow is seen 
at the opposite angle, c is the decidua or 
caduca excreted by the inner surface of the 




PREGNANCY. 155 

womb, covering it as with a soft inductus. d is the vacant cavity of 
the uterus, e the same decidua or caduca, pushed off from the sur- 
face by the globe of the ovum g, which, as it increases in size, thrusts 
the decidua, or reflects it, as in the outlines from e to e. It is this 
part to which the name of decidua reflexa, or caduca reflexa, has been 
given, f indicates the chorion or outer membrane of the ovum. 

It often happens that women miscarry in the early stages of their 
pregnancy; and where the event occurs in the most favorable man- 
ner, the entire product of the gestation is thrust out in an unbroken 
or perfect state. When this occurs, we find, upon examination, 
an oviform or pyriform body, upon the upper segment of which 
is seen a mass of tufted chorion, while the remainder consists of a 
dense and rather solid fleshy mass, which is the original or true 
decidua, called decidua vera. By careful manipulation it is possible 
to extract from the upper part of this mass the complete and perfect 
ovum, consisting of the chorion with its remaining tufts, inside of 
which chorion is the amnion, the water of the amnios, and the 
embryo. 

A good notion of the appearance of the whole decidua, after the ex- 
traction of the ovum, may be got by ex- 
amining Fig. 53, which is pear-shaped. Fi s- 53 - 
The pit or depression at the upper end, 
out of which the ovum was taken, is the 
reflected decidua. It is clear that if the 
ovum should continue to grow, and to 
reflect the decidua, or carry it before it, 
the decidua reflexa would at last come 
in contact with the decidua vera, be 
pressed against it, and that they would 
weld or solder together, so that, at 
length, it would be impossible to sepa- 
rate, or even distinguish them' from each 
other. 

The cavity of the decidua vera, which was a closed sac, was, ac- 
cording to Breschet, filled originally with a fluid. Breschet gave to 
this liquor the denomination of hydro-perione. Of course such hydro- 
perione must be absorbed in the process of reflection, and ultimate 
fusion of the decidua reflexa and vera. We shall find, further on, 
other opinions on this subject. 

Such are the Hunterian views of the decidua. Other explanations 




/:'■ 



::' "_. i . _ " lit- . tt ... ; -- : ;- ztzSzZmL. — _.::. z-:-.. rei 
~ ::: ; :: nifrrsiif . 

. . i t ; : ' : ; . : : . " i . .- . - : : :n . : :=•■: :i t -. i . : . t : . : t : : 
lining in the interior of tbe womb, contending that the corpus nan- 

::?_- .nniiiTes — ::i:i ::: :■= 1.1:1. 21: :il: "if :i:.f: — i_ :f :if 

:':ii:. :: "if rresr-:: 117. :: -f-7 -i T rXisTfi:-: :: i ~i:ii> :-:.:> :; 
s:-zit sir. is :it ?~i-rr£c:zl ris?-r :: :it iif: iirie.; ::zlz :rrn 

Ii I- 1 . C : i 1 e ' s A:". : 
rfiresfiriiz mr—it-i -It" ::' nii Tfxri:!. 11: :n:ir "ifn. ::.7 
whiek ex h i bits Ac appearances seen in a piece cnt fiom flne snb- 
5:11:7 :: 1:7 — :~:. :i ~ i::i if 'i: ::::: '::::: ~7ii::ii7 1" ; T - 
giet much thu :::z: :.r iesirr :: "-..: :::::•:::.:: -is::; : :.- 

:-rfi '-r::::zs::-'.::. :: — .::_• :it 1.- mixe:. ~i::i rtiiz- 
seists a piece cut from the uterus. 

Tie rlri: uni 
i::i:i ::' :if :.:- 
* 1: 7 : r : : 7 s 7 1 " 5 m 7 
i:::ii sm 1:1:7 :.:' 
:i7 111::: ::'::: 



Fis 




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1: 



- ±7 LTT-fLT- 

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7l. 11 1.7 

i" . : : _. 7 

111 ::' "iris 



:_: :£ :j ±6 s-i::. 1:1 seer 1: :"lf iift 
I::::. 11-7 1:1 ::^ : : : ::' V \ -_ 
Das* da Corps organ^ the folk ~ 
:.:: ::. :::t; inn: :: i: 111 :■: 

?.::::i:i ::' 1 1:1: z-:i nil itiji :: 
:it: irrisiri 17 n:::if. ~i:" 
i~::: ::.f Crr11f.11 -75:;. 75 ::' i: :~i:.7i :i 
:izii itiiri.T zi::f i-Tii:ri :in :it ::i, j 
body of the womb, phlagosed, and of ; 



PREGNANCY. 157 

ance, in obedience to the laws of a pre-established harmony, is modi- 
fied as it is in the maramifers, during the season of the rut, and pre- 
pared for the reception of the ovule, whose spontaneous maturation 
is about to occasion its fall. 

"While, indeed, the ovarian capsule that is about to burst becomes 
the seat of this rapid evolution, the vascular apparatus of the womb 
is developed and injected in an extraordinary manner; that of the 
mucous membrane especially, forms at the surface of the membrane 
beneath the delicate layer of epithelium with which it is invested, an 
elegant network with irregularly lozenge-shaped meshes, each of 
which incloses the orifice of one of the innumerable glandular tubes 
of which it almost wholly consists. This vascular reticulation is so 
decided and so rich, that in certain subjects it communicates to the 
inner surface of the womb a more or less violaceous hue. In all 
probability it is through these delicate ramuscles of which the net- 
work consists, that the menstrual blood oozes. In cases where a 
pregnancy has become somewhat advanced, and the ovum, lodged 
upon the mucous surface, has affected it so as to cause it to assume 
all the characteristic features of the caduca, these ramuscles become 
so greatly developed, that many of them attain the size of a quill- 
barrel. A definite opinion may now be obtained of their real 
nature, and we may feel convinced that the major portion of this sub- 
stance belongs to the venous system ; — so that the mensual hemor- 
rhage which they yield, is evidently, in chief, derived from the reser- 
voir of the black blood." 

****** 

"These glandular tubes, one end of which is related to the mus- 
cular layer, while the other opens upon the free surface of the mucous 
membrane, are in number so considerable, that their orifices give the 
appearance of a strainer to the surface. Their presence in the tissue 
of the membrane increases its thickness to such a degree that in many 
subjects, it forms plica?, or elevated convolutions, that are soft, com- 
pressed, and so jammed together, as to leave no void space in the 
cavity of the womb. These convolutions, when the ovum descends 
from the tube, seize it and retain it by their contact or pressure. 
Upon inspecting the extraordinary thickness of this membrane, one 
might be led to suppose it the seat of a true pathological hypertrophy, 
or other alteration, were it not that repeated experience, corroborated 
by the examination of the parts, in women dying of accidents at the 
commencement of pregnancy, afford us the undeniable proofs of its 
being a normal condition of things." 



158 



PREGNANCY. 



M. Coste's engravings give very beautiful illustrations of the asser- 
tions of the above paragraph, and I have the pleasure to bear witness 
to the fidelity of at least one of his pictures, of which he presented 
me with an engraved and colored copy while I was in Paris in 1845. 
Not only was that engraving a most faithful copy of the water-color 
drawing, but M. Coste had the kindness to show me the anatomical 
specimen from which the drawing was made. It is impossible for the 
art to give a more perfect representation of an object. 

In the course of the researches that I made in the years 1847-8, 
upon the reproduction of the Opossum, I had occasion to examine the 
uteri of many of those animals both in the gravid and non-gravid 

Fig. 55. 




state. I present to the reader an outline drawing of the uro-genital 
apparatus of that singular animal, which is a monotreme. In this 
figure a is the urinary bladder ; bb, the first wombs ; cc, the second- 
ary wombs; dd, the ovaria; e, the uro-genital sinus along the surface 
of which (e) laid the rectum. The sinus uro-genitalis and the rec- 
tum united in a cloaca or monotrematous sac, which, as in the birds, 
gave outlet to the products of digestion, urination, and conception. 



PREGNANCY. 



159 



I examined this animal on the 3d of April, 1847, and found seven 
marsupial embryons in the pouch, which, from their size, I have rea- 
son to suppose must have come into the marsupium about the 10th of 
March, as they compare with my specimens of the 7th of March. 

This figure represents the bladder, wombs, and sinus, inflated by 
the blowpipe. The wombs bb, when the animal is in rut, become 
twice or nearly thrice as large as they are in the figure; and the in- 
creased magnitude depends solely upon the development of the tubuli, 
of which M. Coste speaks in the above quotation. The cavity is very 
minute — bean-shaped, and filled with an apparently slimy matter. 

In an opossum examined last winter, there being present Drs. I. 
Wallace and E. Wallace, the aorta was injected with size colored 
with vermilion. Much of the injection was found to be effused into 
the small bean-shaped cavity of the wombs bb — but there were a 
great multitude of straight tubuli standing vertically as to the paries 
of the womb, that were filled with the red injection, presenting the ap- 
pearance of waving, or straight red lines, passing from the inner super- 
ficies of the substance of the womb down through the soft deciduous 
matter to the inner delimitation of it. The cut, Fig. 56, gives a pretty 
correct view of the appear- 
ances presented upon cut- 
ting one of the wombs open 
in its longitudinal diameter. 
The lenticular-shaped ca- 
vity is seen in it as well as 
the converging tubuli. It 
gives also a good idea of 
the thickness of the uterine 
walls, compared with the 
accidentally developed interior membrane. On the exterior of the 
womb is seen the ovary, with part of its cornu, or Fallopian tube. I 
think no one who has examined M. Coste's engraving of the gravid 
womb, opened, can fail to be struck with the immense comparative 
development of the uterine tubuli during the rut of the opossum. It 
is among the apparent slimes of this texture, that the Rev. Dr. Bach- 
man, of Charleston, S. C, found the young embryons moving — as ex- 
pressed in his paper to the Philad. Acad, of Natural Sciences, 1848. 

I in vain searched for such free embryos in the numerous speci- 
mens of Didelphis in rut that I examined with the Drs. Wallace. 
We discovered none. 

Having sent specimens of these wombs to Professor Owen this 



Fig. 56. 




160 PREGNANCY. 

spring, I ought, perhaps, to wait for his superior judgment upon the 
subject ; but I venture, in the mean time, to call attention to the simi- 
larity of the tubular appearance in those wombs, to that discovered in 
the human uterus by M. Coste, and of which I have already presented 
the copy of an engraved specimen on page 156, taken from that ad- 
mirable physiologist. 

I leave it to the Student now to judge for himself, as to the nature 
of the deciduous coat of the womb ; and to decide betwixt the Hun- 
terian explanation of it, already given, and the new doctrine, of which 
he has here the sufficient elements, for the purpose of making up his 
opinion. 

The ovum, after reaching the uterine cavity, grows rapidly. At 
first, it must be supposed to augment in consequence of an act of en- 
dosmose, which conveys to its interior, the cytoblastema that it finds 
in the mucous fluids amidst which it exists. 

Gradually developing its substance by means of changes in the 
vitellary mass that attends it, and also, probably, by means of a 
pabulum it finds in the mucus, by which it is surrounded, it soon 
commences the acts of evolution of its parts. This process is effected 
by sending forth to all its parts, by means of the ventricles of the heart, 
the sanguine materials which it creates in order that it may be so 
converted. 

As the foundations of the tissues are being built up in these histo- 
logical deposits, the nervous mass is everywhere deposited among 
them, and is in fact their essential element This nervous mass, in 
the form of nervous fibrils and cords, like all the rest of the solids, is 
derived from the blood — for nothing is truer than Oken's assertion, 
that " The blood is the fluid body, and the body the fixed and rigid 
blood," so that the whole of the developments of the embryo and 
foetus are the results of organic deposits, henceforth derived from its 
blood alone. 

The embryo requires an engine for the circulation of its blood. 
Hence the features of the heart become so early disclosed — the path of 
the aorta is laid out by the blood itself; and the omphalo-mesenteric 
vessels are traced in order that the functions of the umbilical vesicle 
may not fail. 

The aorta divides as it grows longer, into two branches, which are 
not two primitive iliacs, but two umbilical arteries, designed to send the 
blood of the embryo to circulate near the mother's blood, and to take 
from it the quantity of oxygen requisite for its aeration, and a certain 
plasma which it brings back to the body of the embryo. These two 



PREGNANCY. 161 

umbilical arteries give off branches which become, at length, suffi- 
ciently large to be demonstrated as the external iliacs, the femorals, 
the popliteals, &c, for the vessels of the limb are productions from the 
umbilicals which, at last, assume their permanent character as iliacs, 
femorals, popliteals, &c. The blood of the embryo, by the extension 
of its umbilical vessels, comes at last to circulate among the cellular 
mass that is developed on the outer surface of the chorion, amidst 
which it receives its supplies of oxygen and also its alible elements. 
As the embryo is now enclosed within its amnion, chorion, decidua 
reflexa, and decidua uterina, it cannot be considered, of itself, to have 
any contact with the maternal surfaces — nor has it any connection 
w T ith the mother, save by its blood alone, which it sends forth, pro- 
jecting it, so to speak, far beyond the limits of its own body, in the 
distal tufts of the branches of its umbilical vessels, to spread it upon 
the living wall of its mother's tissues, there to receive its endowment 
of oxygen. 

The only part of the child that touches the mother 
is the blood of the child. 

The embryonal blood having traversed the capillary system of the 
placental tufts, returns by the channel of the umbilical veins. All 
the umbilical venules, in their inchoate state, have, probably, the 
power of taking up, by endosmose or absorption, some species of 
plasma or cytoblastema, from the maternal surfaces. They convey 
this, together with the aerated blood of the umbilical capillaries, into 
the single tube of the umbilical vein, which delivers it back to the 
child, by pouring it partly into the hepatic porta, and partly into the 
inferior cava by way of the ductus venosus. 

In speaking of the absorptive power on the placental venules, I 
do not wish to be considered as asserting a power of absorption like 
that of the lacteal and lymphatic apparatus. I mention the fact — and 
I do not wish to state that the act is done by any other than the en- 
dosmose power; for I do not venture to suppose the existence of regu- 
lar absorbent vessels in the mass of the placenta, where no efforts 
have yet succeeded in making them manifest. Professor Liebig's 
Researches on the motion of the Juices in the animal body, may be 
one's sufficient warrant to believe that the placenta can take up from 
the maternal tissues an amount of organic material adequate to the 
development of the uterine embryo and foetus. 

While the embryo is growing, the amnios continues to fill with 
larger and still larger quantities of water, the placenta increases in 
11 



162 PREGNANCY. 

size, and the womb, which affords the nidus for the tender young, aug- 
ments pari passu, with the ovum and its contents. 

The womb yields to the antagonistic force of the expanding ovum, 
It undergoes a compulsory development. The womb always resists 
this expanding power; it makes daily and perhaps hourly efforts to 
cast forth the burden from its cavity. 

But, the ovum commences its career of development in the cavity 
of the womb, which is composed of the wall of the fundus and cor- 
pus uteri. 

The long cylindrical cervix is not, at first, interested in the strug- 
gle or contest between the expanding ovum and the resisting cavity. 
It stands as the guardian of the fruit of the conception. The cervix 
uteri is the seat of what the ancients called the facultas retentrix, and 
it continues superior in force to the facultas expultrix until the close 
of pregnancy, when being abolished, the facultas expultrix acquires 
sole dominion, and labor commences. 

If at any time, during the course of a pregnancy, the retentive 
power of the cervix should fail, the expulsive power of the fundus and 
corpus uteri immediately begins to expel the ovum. 

Many of the abortions that we meet with are caused by the weak- 
ness of the womb — that is to say, by the weakness of the cervix uteri, 
which gradually yields to the antagonizing contraction of the body 
and fundus, and allows the ovum to come forth and be lost. The 
physician makes use of this principle in the treatment of cases in 
which the indication is plain to bring on premature labor. If he di- 
lates the canal of the cervix with his finger, or with a sponge tent, 
he takes away the facultas retentrix, and the ovum comes off. 

While the uterus is thus the reluctant agent of the forces of the 
ovum, it gradually increases in volume and weight, as well as in the 
cubic content of its cavity. After labor, it weighs a pound and a half: 
in the non-gravid state, it weighs two ounces and a half. It follows, 
therefore, that in the course of a gestation, a vast increment of its 
mass takes place, and that this whole sum consists in living organic 
molecules or living solids, that are deposited within its limits and be- 
come constituents of them. 

Under what power is it that so great a mutation is effected? 

There is no other mode to explain it, than by reference to the aug- 
mented intenseness of the action of its nervous mass, compelling the 
organotrophic operations at the expense of the blood brought into it 
by the uterine and spermatic vessels ; for Oken says, truly, that the 
blood is the fluid body, and the body the fixed and rigid blood. 



PREGNANCY. 163 

I shall not endeavor to give the rationale of the influence exercised 
upon this nervous mass by the growing ovum. Perhaps John Hunter 
would ascribe it to the stimulus of distension. Suffice it for me to say, 
that at any time in the course of the whole career, that career may 
be instantly arrested, and brought to a close, by destroying or with- 
drawing the ovum, or by taking away the retentive power of the cer- 
vix uteri ; for, to discharge the waters of the amnios by puncture, to 
dilate the canal of the cervix with a sponge-tent, or to energize im- 
moderately the facultas expultrix of the fundus and corpus uteri by 
means of ergot, is to arrest and bring to a close the whole operations 
of the reproductive processes. 

But as the womb grows larger, its arteries and veins become elon- 
gated — their coats become more considerable in size and weight. 
The nerves are enlarged, or, at least, they are extended, or produced. 
The absorbents, in like manner, are augmented, and more than all, 
the great masses of muscular tissue existing in the virgin womb in 
potentid, rather than in reality, acquire a visible and palpable magni- 
tude and force. 

As the womb expands, driven outwards in every dimension from 
its centre, its walls do not diminish in thickness, although they be- 
come softer and more succulent. Torrents of blood circulate in the 
tortuous branches of the uterine arteries, and soak along in the im- 
mense sinuses and veins, some of which are large enough freely to 
admit a finger in their cavities. 

In the development of the veins in the gravid womb, the fibrous 
coats of them do not appear to undergo much change or addition. It 
is the lining membrane, the endangium, that is chiefly increased, pari 
passu, with the augmentation of the calibre of the vessels, so that in 
examining the gravid womb, one sees rather great holes and channels 
lined with a smooth endangium, running among the tissue, than real 
veins. In this respect there is nothing peculiar to the womb, since it 
has been long known that the veins within a viscus consist only of 
the endangium, as must indeed have been the case in the earliest 
stages of development even of the aorta itself, for the blood makes its 
own channel. It makes therefore its endangium first, and the more 
tough, fibrous, and elastic parts of the tubes afterwards. 

From the foregoing, it appears that the augmentation in weight, 
volume, and capacity of the gravid womb, is a compulsory process 
under an antagonistic force applied and sustained by the developing 
ovum. The ovum may be compared to a powerful acephalocyst that 
attaches itself by means of its placental mass, serving as its absorp- 



164 PREGNANCY. 

tive organ, to the living wall of the womb, which it compels to yield 
in every dimension for its growing wants of accommodation. 

The womb increases in weight as the pregnancy proceeds. The 
means of its suspension in the cavity of the pelvis are always the same 
in the gravid as in the early non-gravid state. It is to be expected, 
then, that as the uterus becomes heavier, it shall sink somewhat lower 
down, and that the woman shall, if she be a susceptible creature, 
perceive some symptoms like those of a falling of the womb. 

Although the womb is growing larger, the lower part of the abdo- 
men does not become larger. On the contrary, the early sinking 
downwards of the womb causes the hypogastrium, in some cases, to 
be less protuberant than before the conception, and hence the French 
proverb, 

" A ventre plat 
Enfant il y a." 

These signs of falling of the womb in women who are married, 
should be ever by the physician held in suspicion, until he has full 
reason to believe that they are not results of an early pregnancy, 
and there is frequently no little embarrassment for him in coming to 
a positive conclusion. Even the vaginal taxis cannot, in all instances, 
give him an assured ground of opinion, since the engorgement of 
the uterus, so frequently coincident with its prolapsions, are with dif- 
ficulty to be distinguished from the augmented volume of the same 
organ arising from gravidity. 

The reproductive organs have a direct connection with the cerebro- 
spinal and the ganglionic system of innervations. There is, therefore, 
no part nor parcel of the economy, into relation with which it cannot, 
under certain states of health, be brought. They are among the most 
powerful disturbers of the complacency of the organisms. They con- 
stitute an imperium in imperio, whose behests are not to be dis- 
obeyed. 

These organs can disturb the brain — the respiration — the digestion 
— the circulation — the secretions — the nutrition. 

When the womb has become the seat of an advancing gestation, 
and feels the impulse of development, the complacency of the other 
innervations is discomposed. The stomach is one of the organs ear- 
liest to be called into consentaneous distress. The sympathy of the 
stomach is, in general, independent of any marked change of the tem- 
perature, and of the rate of the arterial pulse. It is expressed by 
anorexia — by nausea, and oft-times by vomiting. Probably the sali- 
vation, which is also a common symptom in pregnancy, is one of the 



PREGNANCY. 165 

same category of disturbances — as is also the sore-mouth of pregnant 
and suckling women. 

Multitudes of women suffer from nausea only in the morning hours, 
the sympathy being interrupted by the business, the preoccupation, 
and the fatigues of the day, to return again on the following morning 
and follow the same course. In others, the nausea is perpetual — and 
attended with the most obstinate vomiting. 

A young woman, under my care, vomited very soon after the con- 
ception. She vomited every day, and many times daily during the 
whole course of her pregnancy. When her labor came on, which 
was a fierce one, her disposition to vomit was greatly aggravated with 
every renewal of the contractions. To such a height did this symp- 
tom rise that I found it seriously to contravene the intent and purpose 
of the labor pains. It is not a good practice, in general, to rupture 
the membranes of a primipara ; but in this instance I concluded, that 
if the ovum could be allowed to discharge the waters, the condensa- 
tion of the womb that would follow might put an end to the vomit- 
ing. I thrust my index finger through the distended bag of waters at 
the next pain. From that moment the nine-months' vomiting ceased 
and returned no more. The labor, no longer delayed and contravened 
by the troublesome vomiting, hastened to a favorable conclusion. 

When the student, having finished his early studies, shall have ad- 
vanced to the higher grade of the scholar and counselor, he will meet 
with numerous occasions to feel astonished at the perverseness of the 
nausea and vomiting of pregnancy, as well as the enormous discharges 
of saliva protracted through weeks and months of distress. 

I attended a lady in Spruce street, a few years since, who, during 
nearly three consecutive months, appeared to vomit up every particle 
of her ingesta. It was her own opinion, coincided in by her friends 
and attendants, that the total amount of all her food and drinks re- 
turned very soon after they were swallowed. Although she felt much 
weakened, I could not perceive that, under this process, she lost her 
flesh, and in the end, she gave birth to a healthy daughter. It is 
apparent that she must have been nourished during this time — but 
the manner, and the quantity, have remained ever since a mystery 
that I cannot explain. I cite this as one case only out of a great 
number that have occurred in my practice. 

In my Letters on Females and their Diseases, p. 483, is the account 
of a case of vomiting from pregnancy, which brought the woman's 
life into great peril. I made the first note of her case in my case- 
book, Sept. 18th, 1842. She had then been vomiting since the first 



166 PREGNANCY. 

days of April. She assured rue she had rc-mited more than thirty 
times daily, and her mother, a prudent, sensible woman, said that she 
had vomited more than sixty times a-day. This vomiting ceased 
upon the use of large quantities of champagne. Upon some impru- 
dences in exercise and diet, the vomiting returned, and continued 
until the child was born. She was frightfully reduced — to such a 
degree, indeed, that at the eighth month I was nearly decided to bring 
on premature labor. Certain motives having dissuaded me from that 
step, she finally was delivered and recovered her health. 

Now, such a case of vomiting ought not, by the Student, to be 
regarded as a case of sympathetic disturbance of the stomach merely. 
It is true that the earliest manifestations of the gastric disorder are 
attributable to sympathy with the womb ; but when the malady has 
attained so fearful a height, it becomes itself the primary disorder, 
and cannot be correctly explained but as an actual inflammation of 
the stomach and duodenum, with grave derangements of the circu- 
lation and secretions of the liver itself. This woman discharged im- 
mense quantities of brown, ropy mucus, often charged with red 
blood. The epithelium of the stomach and duodenum was unques- 
tionably in many places removed, leaving the corpus mucosum bare, 
or raw. 

If I had fulfilled my design to bring on a premature labor, I should 
not thereby, perhaps, have cured the gastro- enteritis; but by removing 
another and considerable cause of constitutional disturbance, her con- 
stitution would have been earlier left at liberty to recall the gastro- 
duodenal and hepatic tissues to their wonted rates of vital activity. 
The woman did, in fact, recover after the birth of her child. 

If the digestive organs are susceptible of such great deviations of 
their activity as those I have above mentioned, they will, a fortiori, be 
liable to slighter manifestations of derangement; as by acidity, eruc- 
tations, flatulency, and irregular action of the bowels, either as cos- 
tive or as the subjects of diarrhoea. 

Many of these troubles vanish while the woman takes exercise in 
her carriage or on foot; because, as before said, the powers of the 
constitution, when devoted to the purposes supposed in every case of 
active employment, are not liable to be checked and diverted by a 
patible consent of the stomach with the womb. Hence such women 
should be advised to walk or ride, or to busy themselves with their 
affairs, and avoid a sedentary and slothful life. 

The acidity and eructations, and the diarrhoea or costiveness of 
pregnancy may be obviated by the use of alkalies, whether soda or 



PREGNANCY. 167 

potash, magnesia, lime, or ammonia. Some vigor maybe communi- 
cated to the gastric innervations by means of champagne; or by 
brandy and water, rum and water, or by certain of the bitter spirit- 
uous tinctures, combined with aperients. 

I readily cured a case of this sort, in the spring of 1848, in a person 
who had suffered great distress from vomiting, cardialgia, flatulency, 
and constipation. She had a mixture composed of sweet tincture of 
rhubarb tw T o ounces, and tincture of gentian one ounce. A dessert- 
spoonful of this medicine, taken once a day, dissipated all the symp- 
toms. Two drops of tincture of aconite, in a tablespoonful of water, 
may be given for the dose, in certain of the cases, with marked relief. 

Many of those examples that consist of nausea and vomiting during 
the early part of the day, but which cease after the meridian hour, 
may be set aside by the following method : — 

Let a cup of coffee, with a toast, be brought to the bed-side at the 
earliest morning hour. The patient should be called from her sleep 
to take this preliminary breakfast, without rising from bed. As soon 
as it is taken let her lie down to sleep again, if possible. 

It appears useless to offer a rationale of this method. I am very 
confident, however, that, in a considerable number of persons, it will 
be found to put a sudden stop to the vomiting, as well as to the 
nausea. Certainly, many of my patients have been speedily, as well 
as permanently cured by it, and that in very distressing instances of 
the nausea. 

Inasmuch as the gravidity of the womb enables it to disturb the 
alimentary organs in the manner above mentioned, it might reason- 
ably be inferred that the rest of the nervous mass is also liable to 
interruption of its regular action, from similar causes. In regard to 
the temper and disposition of the woman, considerable modifications 
are sometimes observable. Those who are by nature amiable and 
gentle, become peevish, and fretted by trifles — full of false alarms and 
idle fears; while persons naturally ill-tempered, become charitable, 
and kind, and courageous. Strange desires, longings, wishes for 
extraordinary, unprocurable, or disgusting kinds of aliment, are said 
to arise in pregnant women; but in a long clinical practice I have 
never met with any examples of the sort ; which leads me to infer 
that these longings are more frequent in the books than in the practice 
of our art. 

Quickening. — The child acquires a power of slight muscular mo- 
tion at an early stage of pregnancy; but, as it is defended by the 



168 PREGNANCY. 

decidua and the membranes, and floats in an abundant liquor amnii, 
the first feeble motions of its body or limbs cannot make themselves 
felt, through so many coverings, by the living tissue of the womb. 
In general, the embryo attains the age of four months and a half be- 
fore it becomes sufficiently large and strong to make itself felt by the 
mother when thrusting with its feet or hands, or when suddenly re- 
dressing its body from its usually flexed position. 

When the child hath first acquired this power to make its motion 
felt by the mother, it is said to be quick with life, or to have quick- 
ened, and the event is called the quickening. 

The lawyers have looked upon a child quick with life, as worthy of 
the protection of the laws ; for it is felony, maliciously, and with evil 
intent, to kill a child that is quick with life in the womb, but not 
felony to kill one that is not quick with life. It appears to me that 
there is here a distinction without a difference; for the child of six 
weeks or of two months is as essentially quick with life as one of five 
or seven, or even of nine months. It is to be hoped that this barba- 
rous and ignorant distinction, a remnant of early legislation, may be 
done away with by our modern legislatures, and that the wretches 
who for hire lend our art to the detestable baseness teneros avellere 
foetus, may be liable to condign punishment for the crime, committed 
at whatever stage of the gestation. 

It was formerly proposed to explain this occurrence of quicken- 
ing by supposing that the womb just at that time, having grown too 
large to remain in the cavity of the pelvis, suddenly escapes from it 
into the free abdomen above, and that the suddenness of its rise and 
intrusion is the cause of the first sensation. But I conceive that no 
one now adopts such an opinion. 
X As the ovum grows larger day by day, so doth the womb continue 

to expand, adding molecule to molecule, weight to weight, and mass 
to mass. The lower belly becomes visibly protuberant, and the 
swelling is one fashioned upon the pear-shaped womb that lies beneath 
and pushes the belly outwards. The Student should remember that 
other bodies besides the womb may cause the abdomen to enlarge — ■ 
but that no object save the uterus itself can give to the hypogaster 
its peculiar gravid shape. 

The form of the hypogastric tumor dependent on the state of 
gravidity, furnishes to the physician a very useful means of diagnosis, 
which ought not to be neglected in some of the difficult cases ; cases 
in which it is a matter of extreme consequence to individuals that no 
mistake should be made as to the real nature of the symptoms. 



PREGNANCY. 169 

The navel is, in the non-gravid woman, a deep depression or dim- 
ple. This depression is caused by the contraction or shortening of 
the remainders of the two umbilical arteries and veins, which, after 
the birth, draw the skin inwards and downwards to make the pit of 
the navel. In the gravid woman, when the six months are past, the 
navel rises to the general level of the skin — and, as the womb grows 
larger in its progress, the umbilicus protrudes, because the ligamen- 
tous remainders of the umbilical vessels, wdiich are deployed with the 
rest of the teguments, can no longer draw it inwards. A pouting 
of the navel is, therefore, one of the consequences and signs of a preg- 
nancy of six and more than six months advanced. Other tumors 
also make the navel to pout. 

Sometimes it happens that the gravid womb fills up by its bulk 
the cavity of the pelvis so much as to produce cramps in the legs, by 
pressing too firmly upon and obstructing the sacral and obturator 
nerves. There is no remedy but patience and time. 

When the womb has got fairly up into the cavity of the abdomen, 
it lies in front of the convolutions of the intestines ; even the transverse 
colon lies rather behind the upper part of the fundus; so that, when, 
in a gravid subject, the abdomen is laid open, nothing is to be seen 
but the uterus in front. The edge of the right lobe of the liver, or a 
segment of the greater curvature of the stomach, the omentum, and 
colon lie upon the top towards the reverse of the fundus uteri. 

In this situation it is impossible for the bowels to receive, in the 
same manner and degree the stimulating and natural succussions of 
the abdominal muscles that they receive under ordinary circum- 
stances. Those succussions are constant provocatives to a healthful 
activity of the peristaltic force, and are essential thereto. The failure 
of them tends to render the peristaltic motion languid or torpid, and 
therefore costiveness is a very ordinary state in advanced pregnancy. 
Let the Student reflect upon the evil effects of such torpor, in over- 
loading the alimentary tube with the undischarged residuum of the 
digestion, by which the tension of the abdomen is increased, and the 
mesenteric and hepatic circulations and innervations brought into 
disorder, which ought to be corrected by the proper remedies. 

As the womb approaches nearer to its term of gestation, the reten- 
tive faculty grows gradually less, from the deploying of the upper part 
of the cervix, which becomes a part of the general cavity for the 
accommodation of the ovum. The expulsive faculty makes frequent 
efforts to overcome the antagonism of the cervix. These efforts, 
which doubtless lend a chief aid in the act of deploying the cervix 



170 PREGNANCY. 

uteri, are to be detected in the alternate hardening and softening of 
the globe of the uterus under the hand placed upon the abdomen. If 
the hand be placed upon the abdomen, it may be that the impression 
will first be received of a great softness and pliability of the textures; 
but, upon keeping the palm in situ, the tumor begins to grow harder 
and harder until a very condensed condition of the organ is produced 
by this tonic contraction of its muscular tissue. 

These contractions are not productive of the least pain or any dis- 
agreeable sensation, save a feeling which women designate as a 
" drawing" sensation. One feels surprised, sometimes, upon observ- 
ing the very positive force of these contractions, to hear the woman 
say that they produce no pain in the back or hypogastrium. 

These contractions are repeated very often during many weeks. 
The effect of them is to reduce the cylindrical neck of the womb to 
the shape of a cone — or rather to the form of the lesser pole of an egg, 
and to make the os tincse acquire a circular instead of its usual oblong 
or oval form, and to render it a dimple or a pit in the apex of the 
now oviform uterus. When this dimple has become completely de- 
veloped by the resolution of the cylindrical into the conoid al cervix, 
labor is ready to begin, and the next repetition of the contraction 
might justly be accounted as the first pain of the labor, for the labor 
pain is nothing else than contractions of the organ in which the ex- 
pulsive faculty tends to overcome the retentive faculty, and thus free 
the uterus of its contents, by thrusting them forth into the vagina, and 
thence into the world. 

The uterus rising upwards in the cavity of the belly finally attains 
the length of full twelve inches. I measured the gravid uterus at term, 
in an individual who died suddenly before the onset of labor, during 
the present month of June, 1848. It was twelve inches long, and 
eight inches in transverse diameter. The broad ligaments rise, of 
course, as the womb rises ; and the ligamenta rotunda, which, ex- 
tending from the internal abdominal rings to the angles of the uterus, 
ought not, in a normal state, to be more than two and a half to three 
inches in length, by the mounting upwards of the uterus towards the 
scrobiculus cordis, at last acquire a length of five or six inches at 
least, serving to stay or steady the womb as it goes up, and on occa- 
sions, tending to render it oblique to the right or left, in proportion as 
the right or left ligamentum rotundum is the readiest, or the most re- 
luctant to yield, as the womb rises and compels it to accompany the 
ascent. 

I call the attention of the Student to this condition of these liga- 



PREGNANCY. 171 

ments, now, in order that he may in this connection clearly under- 
stand that if the round ligaments should not diminish their own longi- 
tude pari passu with the lessening of that of the womb after labor, 
and if they should continue elongated, or weak and relaxed, after the 
womb has returned nearly to its non-gravid dimensions, then the 
womb, having no support to prevent it from falling backwards, will 
be liable to dip its fundus below the promontorium, and be overset 
backwards, or retroverted. Whenever this accident, happens, it is 
attributable to a fault of the round ligaments, and to nothing else; 
since, with round ligaments two and a half inches in length, the fun- 
dus could not possibly retreat far enough from the symphysis pubis to 
admit of the state of retroversion. Let the Student early learn that 
one of the common accidents of the lying-in state is this very accident, 
the non-contraction of the ligamenta rotunda — and let him carefully 
estimate the effects, as to obstruction, pain, bearing down, and gene- 
ral disturbance of the health, likely to arise from the accident in ques- 
tion. While he is ignorant of these simple facts in pathology, he 
will permit his patients to suffer needlessly ; but, well informed on 
this point, he will surely obviate by his precautions much sore dis- 
tress. The accident is by no means an uncommon one, after abortion 
at the third or fourth month. In such instances, when the woman is 
found to complain of pain in the back, and within the pelvis, with 
urinary and rectal tenesmus, and be confined to the bed, instead of 
readily recovering, as she might be expected to do, after a few days, 
let the Student look to it, that he make a full exploration for the estab- 
lishment of a sound diagnosis. 

It is proper that I should now recur to the consideration of the 
development of the foetus, and explain its nature as a part of the 
doctrines appertaining to the subject of pregnancy. In doing so, I 
cannot avoid speaking of the appendages of the foetus, for the secun- 
dines, though attached to the new being, and perhaps strictly to be 
considered a part of it, are yet in a degree to be regarded as an ex- 
trinsical and accidental, or transitory apparatus. 

When the Graafian follicle, in completing the acts of ovulation, 
bursts, and discharges its yelk into the infundibulum of the Fallopian 
tube, the ovulum falls off free and unconnected with any part of the 
maternal tissues. It is no more connected with the living parent that 
produced it, than is the bud that is carried by the gardener a dozen 
miles from its original stock to be inoculated into another tree ; yet, 
like it, it is a living, independent and vigorous being. 

The ovulum passes along the canal of the Fallopian tube, aug- 



172 PREGNANCY. 

menting as it goes. The vector tube discharges it into the cavity of 
the womb, where the greater portion of its orb is enveloped in the 
deciduous mass, leaving a segment only of its superficial spongy mass to 
seek a perfect contact, and establish a union with the living wall of 
the maternal tissues. At first it remains unattached, but in process 
of time it becomes fixed to some point of the surface, the outer face 
of its tufted chorion attaching itself to the inner surface of the uterus. 
This fixation constitutes what is called conception. 

Probably the spongioles or tufts of the chorion extend themselves, 
like the roots of a plant in the soil, into the softish deciduous mass 
that the womb has prepared for the purpose. It is only that segment 
of the orb of the ovum that looks directly towards the uterine wall 
which it touches, that preserves the tufts of the chorion which rise 
everywhere in equal abundance from the whole ball. The rest of 
the chorion covered by the decidua reflexa soon loses its tufts, and 
becomes smooth and polished like a serous membrane, save here and 
there a few remaining tufts or spongioles that may be detected, in 
cases of abortion, as late as the fifth month ; as in a sample in my 
collection, and as was the case in Win, Hunter's specimen described 
in his table x, fig. 4. 

The nature of the connection thus formed is the subject of great 
differences of opinion, that have not been settled by the authority of 
John Hunter, who first proposed a rational explanation of this difficult 
point, in his article on the placenta, which may be consulted in his 
volume of papers on the Animal Economy. 

According to Mr. Hunter, the placenta is a symmetrical organ, 
consisting of two parts, one derived from the womb, and the other 
from the child. Seller, in his work Die Gebatirmutter, und das Ei des 
Me?ischen, stoutly denies that the placenta belongs to the mother, and 
Velpeau,in his Ovologie ou Embryologie humaine^. 65, says: "Et j'ose 
affirmer avec plus d'assurance que jamais que le placenta humain est 
entierement foetal." I declare, with greater confidence than ever, that 
the human placenta is entirely foetal. 

While the celebrated Velpeau thus resolutely rejects the Hunterian 
doctrine that there is a uterine portion of the placenta, other very 
eminent persons equally insist that an important portion of the mass 
is actually derived from the womb ; and that whenever it is extruded 
by the contractions of the organ, not only is the foetal portion expelled, 
but the whole of the uterine portion, being detached at the same time, 
comes off with the foetal half; from which, indeed, there is afterwards 



PREGNANCY. 173 

no possibility of separating it, nor even of distinguishing them, the 
one from the other. 

I here venture to remark, that this is not pretended to take place in 
any other animal; certainly not in the ruminants, in whom the ute- 
rine cotyledons and placentules separate completely from each other, 
the womb keeping its own organ, and the embryo carrying its portion 
away with it when expelled. I may here ask whether it is probable 
that so great a difference does really exist in the warm-blooded, respir- 
ing mammals, of which man is one species? 

Prof. Owen, of London, is one of the distinguished, eminent natu- 
ralists who contend that the placenta is constituted of materials, part 
of which belong to the mother and part to the ovum. Mr. Owen says 
that, after having carefully compared the Hunterian preparations with 
the results of his own examinations of the gravid uterus at full period, 
"I now believe they all fully bear out Mr. Hunter's general view, 
viz., that the maternal blood is diffused, by means of the tortuous arte- 
ries, into the spongy cellular substance of the placenta, where it bathes 
the capillaries of the foetal circulation, and is returned by the oblique 
decidual adventitious sinuses and channels into the orifices of the ute- 
rine veins." Vide note in Hunter on the Animal Economy, p. 102. 

M. Flourens, Professor of Comparative Physiology at the Jardin des 
Plantes, says, in his Cours sur la Generation, p. 130, that the umbi- 
lical vessels of the mammifers, which everywhere pierce the chorion, 
in order to come at the internal surface of the womb, are called pla- 
centas. The placenta is an inherent characteristic of viviparous pro- 
duction. It cannot, therefore, exist in the oviparae. Mr. F. divides 
the mammals into two great classes, one of which comprises man, the 
rodentia, and the carnivora; while in the other class are arranged the 
pachydermata, the solipedes, and the ruminantia. In the first class, 
he contends, there is a vascular inosculation of the mother's vessels 
with those of the ovum, whereas no trace of such vascular union can 
be detected in the second. 

I have cited this distinguished physiologist in order to show his 
opinion ; but I am far from advising the Student to adopt it upon his 
authority. His assertion that the placenta is a characteristic of vivipa- 
rous production, is denied by high authority; and notwithstanding I 
am prompted to agree with him, I admit that the most careful research 
has never enabled me to discover the least trace of a placenta in the 
early marsupial embryon, as I have stated in my paper on the Didel- 
phis, in Amer. Phil. Trans. 

Mr. Owen's assertion in regard to these differences in the classes, 



174 PREGNANCY. 

is as follows: — "Thus the placental intercommunication between the 
foetus and mother, in the human subject and quadrumana, is carried 
on by the contact of the foetal capillaries with maternal extravasated 
blood; while in the ruminants, the mare and the sow, it takes place 
by the apposition of capillaries to capillaries, and the two parts of the 
placenta, viz., foetal and maternal, can be separated. In the ferae 
and rodentia there appears to be an intermediate structure." Loc. cit. 

Let the Student, while pondering upon these propositions of Masters 
in our science, observe that, though the separation of the placenta in 
child-birth is essentially hemorrhagic, and not so in the parturition of 
the quadrupeds, which might lead to inferences in favor of a different 
plan of union, yet organs of such vital importance in the economy of 
the genera are not likely to be modeled upon plans absolutely differ- 
ent in creatures so nearly allied in their great types. In all the 
mammifers there is one type for the brain and nerves, one for the 
respiration, one for the circulation, one for the absorption, secretion, 
reproduction, &c, and there should, a fortiori, be but one for the 
great and indispensable branchio-absorptive apparatus of the foetus. 

Fabricius ab Aquapendente says the chorion or the umbilical 
vessels dispersed throughout the chorion, may be applied in two dif- 
ferent ways, of which one is by the mutual inosculation of the terminal 
branches of the umbilical vessels with the uterine veins; and the 
other is by the termini of the umbilical vessels plunging into the 
fleshy substance, like roots into a soil. Fabricius, Opera Omnia, fob 
p. 42; Lips., 1687. 

I might devote many of these pages to a relation of the various con- 
jectures and explanations contained in the Medical Library upon the 
subject of the utero-placental connection. The discussion between 
Eschricht and Weber — the elaborate researches of Breschet, of Vel- 
peau, Flourens, Coste, BischofT, &c. &c, might afford abundant ma- 
terials of citation ; but as I wish to give my own views as to a common 
property in the Republic of Letters, I prefer that the Student or Scholar 
should refer to those writers at first hand, and meanwhile to express 
my own sentiments upon the points under consideration. 

No one, I should suppose, can, for a moment, doubt that the pla- 
centa is the agent of nutritive absorption, at the same time that it 
affords to the embryo the sole means of its oxygenation ; nor, that 
oxygen is as essential as the alible material to its existence and 
growth. 

In order to the effectuation of these two prime objects, there must 
be contact of tissues belonging to the independent foetus, with those 



PREGNANCY. 



175 



of the parent; and as the foetus itself is completely separated from the 
mother by its interposed chorion, amnion, decidua, and waters, it 
must develop an apparatus, by means of which to project its blood 
far beyond the limits of its own body into a system of placental capil- 
laries. It is to be supposed that, in these capillaries, the blood gives 
off carbon and receives oxygen, either after the manner of lungs, or 
branchise; and, at the same time, drinks in, by endosmose or by real 
absorption, the fluid materials, out of which to maintain and augment 
its own crasis and sum. 

In this apparatus for projecting the blood of the foetus beyond its 
real limits, and bringing it back again augmented and oxygenated, the 
aorta, as I have already said, divides into two umbilical vessels, which, 
running outwards along the cord, subdivide at its extremity into 
myriads of arterioles and capillaries, which, constituting numerous 
tufts or branches connected together by a loose cellular tissue, is called 
the placenta. These capillary tufts, wherever they may be attached, 
are placentas. 

In the human placenta, and in those of certain quadrupeds, all 
these placental tufts are united into a single disc, cake, or placenta, 
as in the adjoining fig. 57, which shows the uterine surface, where 
the lobules of the placenta are seen divided by the lines of the septa. 
These lobules are very numerous; and if, instead of being assembled 
in one disc, they were disseminated over various parts of the womb, 
the analogy to the ruminant organ would be greater. Fig. 58 ex- 



Fiff. 57. 



Fig. 58. 





hibits the foetal surface of the placenta. The umbilical cord contain- 
ing its two arteries and its vein, is seen reaching the placenta at its 
centre, and dividing its vessels into numerous branches, which radiate 
towards the circumference. In other animals, as the ruminants, the 



176 



PREGNANCY. 



tufts are separated from each other and distributed to different parts 
of the chorion, so as to make a great number of placentas. In certain 
other genera, the tufts consist of zones, surrounding the oval ovum, 
or they are scattered everywhere like a paste over the entire super- 
ficies of the ovum. 

I have counted one hundred and twenty placentas upon the chorion 
of a cow. 

Now, it happens that, when, in a quadruped, these variously formed 
placentas are detached in the act of parturition and expelled from the 
womb, no blood follows the detachment — nor do we ever hear of the 
uterine hemorrhages in the mammifers that so frequently in the wo- 
man render labors alarming and dangerous. Yet, the foetus of the 
larger quadrupeds is evolved and completely nourished by an appa- 
ratus which, to be capable of supplying it w T ith alible matter and oxy- 
gen, might be deemed to require at least as absolute a union of the 
uterus and placenta as is contended for by Hunter and his advocates, 
as to the human organ. It is said that the fcetus of the whale is up- 
wards of twenty feet in length at term. To develop so enormous a 
product, one might well suppose a union as close as that in the 
human embryo, which is only eighteen inches long, and of the weight 
of seven pounds. It is not pretended, however, that the parturition 
of the mysticetus is hemorrhagic; nor that there is a deciduous coat of 
the womb that is converted into what Hunter calls a maternal placenta. 

To develop an embryo is, therefore, a possible power, independent 
of a vascular union or a maternal placenta. Those, therefore, who 
contend for the truth of the Hunterian explanation, do so on the ground 
of a supposed fact, and not on one of a necessity. But, as the largest 
mammal foetuses do not require it, it would appear to be reasonable, at 
least, not to adopt the theory in man, except upon anatomical conviction. 

The placentules of 



Fig. 59. 




■M0WL. 



the ruminants consist 
of very large villi which 
interlock with similar 
villi, or rather, digita- 
tions that rise up from 
the cotyledons on the 
inner aspect of the 
womb. I add here in 
fig. 59, a view of them 
in which the placentule 
is seen drawn out of the 
cotyledon. 



PREGNANCY. 177 

Let the Student procure from the butcher's shambles, the gravid 
uterus of a sheep or cow, and carefully separate, one by one, the 
one hundred and twenty placentas from their one hundred and twenty 
uterine cotyledons, and let him judge whether or no there is, or ever 
could be any vascular union between them, and whether the womb 
furnishes any portion of the placental mass that is throw T n off in par- 
turition. If he repeats the same experiment as to the sow, the rat, 
the rabbit, the bitch, and the mare, he will be surprised afterwards 
to contemplate the drawings and representations, in the books, of the 
microscopic appearances discovered in the human placenta. The 
engravings, for example, in Breschet's w>ork, will seem to represent 
rather the imagination of the artist than the truth of nature ; and I 
may make the same remark as to Ritgen's beautiful picture in his 
Beitrage, and to Dr. William Hunter's nineteenth plate. 

To possess a gravid womb at term, and to enjoy an opportunity to 
examine it carefully, is to be what Noortwyck calls rarissimum hocce 
spolium mactus. Even in London, Professor Owen appears to have 
w T aited long before obtaining such a privilege. 

I have enjoyed but few such opportunities during a long course of 
business in a great city. Those I have had were as carefully im- 
proved as my means would admit; and as I must confide in myown, 
rather than in other men's senses, I find it impossible, under my own 
observations, to adopt the views of the Hunters, and I prefer the opin- 
ions of Seiler and of Velpeau. One ought not lightly to dissent from 
such authorities, nor is it without a sentiment of profound respect for 
the Hunters, that I claim the privilege to see with my ow 7 n eyes, in a 
matter so authoritatively determined by those great benefactors of 
Medicine. 

In w T hat is called Deliverance, the whole placenta comes off 
from the womb. As a general rule, it is separated from its sessile 
position on the vault of the fundus, by the same pain that chases the 
buttock of the child into the vagina, and is completely extruded from 
the genital fissure in about ten minutes. Sometimes it is expelled 
within twenty minutes after the ■/ommencemeni of a labor. 

I have removed a vast number of placentas without staining the 
hand w T ith blood, or perceiving a drop upon the mass itself. 

The placenta comes off with equal readiness at the third, fifth, or 
the ninth month, showing that no other action of the womb is required 
for its expulsion than that of its muscular tissue, and that all times* 
and stages are indifferent as to the facility. 

I find that, in dissecting the gravid womb at full term, the slightest 
12 



178 PREGNANCY. 

traction suffices to remove the placenta from the surface where it had 
ever before enjoyed an undisturbed attachment ; and that, too, very 
soon after death. I am convinced that the connection may be broken 
up even by puffs of air from the blow-pipe; and that it is not more 
adherent than is the peel of a perfectly ripe orange to the fruit. Can 
it be that the womb may exfoliate its half of the placenta with such 
amazing facility, and that, too, in all the stages of pregnancies. Do 
these facts consist with the idea that arteries pass from the womb 
into the placenta? Are other arteries broken so easily? 

I have already mentioned, at page 170, the case of a lady who died 
here in June, 1848. In that necroscopy, in presence of Dr. Yardley 
and Dr. Wallace, I detached the whole of the placenta from the womb, 
after the careful injection made of the aorta by Dr. Wallace, an ex- 
pert anatomist, who had secured the external iliacs before throwing 
the injection into the trunk. 

Neither I, nor those gentlemen, upon the most minute and careful 
search, aided by good lenses, could verify the existence of even a 
single vessel passing from the womb to the placenta. Much of the 
injection was effused into the cellular meshes of the placenta. It was 
an infiltration of the material, and not an injection, in the anatomical 
sense of the term. 

We arose from the dissection, equally and unanimously convinced 
that we had not seen a single vessel broken off, or pulled out, in the 
slow, gentle, and most careful divulsion of the two utero-placental 
surfaces. This examination was made within less than twenty-four 
hours after the demise of the lady. 

During the epidemic of cholera here, I examined a womb within a 
very few hours after the death of the woman, in company with the late 
Dr. J. Hopkinson, then prosector at the University of Pennsylvania. 
He, though an able anatomist, was unable, as I was, to detect anything 
broken, save mucous tractus, though the light and the glasses were 
good, and the most scrupulous care was used, without precipitation 
or rudeness in the operation. 

A similar opportunity was enjoyed, a few years since, at the Penn- 
sylvania Hospital, in a womb gravid with twins. Here, also, I de- 
tected nothing but mucous tractus. Another very fine specimen, at 
the seventh month, was afforded to me by Professor Pancoast at the 
Jefferson College. In this case, many medical students observed the 
divulsion of the surfaces without detecting any vessels. 

These are the opinions I adopt — but when so many explanations 
abound, who is he that can feel perfectly assured of the soundness of 



PREGNANCY. 179 

his own ? There is perhaps a strong argument against these opinions 
which I conceive it a duty to state ; for that which I desire is, the truth. 
The argument may be presented as follows: 

The lining membrane of both veins and arteries, w T hich Bichat calls 
membrane commune, and which by Burdach is denominated endan- 
gium, is the true blood-vessel, the fibrous and elastic coats being mere 
additamenta and fortifications of the genuine blood-vessel. In the 
depths or interior of the viscera, the endangium is applied directly to 
the gangue of the viscus, which gives to venous sinuses the appearance 
of mere cells or cavities, particularly in the womb, where they are in 
some instances as large as a finger. It is a faculty of blood in 
motion, to make a channel or vessel for itself, which vessel is found 
to be lined with endangium. As the womb expands in pregnancy, 
the orifices of vessels upon its inner wall become more and more 
capacious, and possibly the endangium of some of these orifices may 
be extended, forced, driven, or deeply impressed among the delicate 
spongioles and tufts of the chorion, giving rise to the appearance of 
vascular cylinders plunging into the placenta, or passing from it to 
the womb, and thus uniting the two surfaces, uterine and placental. 

To examine Wm. Noortwyck's, Hunter's, Lee's and Ritgen's plates, 
is to perceive that the number of these communications, if they really 
exist, (and I have never been able to detect them,) cannot, from their 
fewness, be supposed to exert any conformable influence upon the great 
branchio-absorptive operations of the mammal placenta. Hence, I con- 
clude, that where such endangial tubes have been detected passing 
across the surfaces, their existence has been accidental, and that they 
do not exist as a normal indispensable part of the machinery of the 
organs. I repeat, that if arteries and veins were naturally existent in 
this place, the divulsion of the surfaces in labor, or artificially, would 
require a force far exceeding that wdiich is usually required to effect 
their separation. 

As to the idea that the blood of the uterus is freely poured into the 
cellular meshes of the placenta, (an act of absolute extravasation,) 
and that the placental capillaries acquire their oxygen and plasma 
from being bathed with that effusion — I can by no means adopt it, 
seeing it is contrary to all analogy in any conspectus of the circulation. 

Blastoderm. — The child continues in the womb during nine 
months, or two hundred and eighty days, according to the common 
computation or reckoning. This is the length of time required for the 



180 PREGNANCY. 

evolution of all its parts, which may be supposed to have existed in 
potentid in the ovarian germ. 

At the commencement it was a mere membrane or blasto-derm, so 
called from jSxaero? a germ, and s?^a skin, commonly called germinal 
membrane. This is what, in the hen's egg, is called the cicatricula 
or the tread, and is supposed to be divisible into three layers or strata, 
of which the inferior, or that which looks inward towards the centre 
of the yelk, is the mucous layer, the outer one the serous layer, and 
the middle or interposed one the vascular layer. The mucous layer 
is deemed to be the basis of the digestive tube, the serous layer is 
held to give origin to the skin and muscles, &c, and the vascular layer 
is devoted to the development of the heart and circulatory apparatus. 

Such is the doctrine inculcated by some of the writers on Embryo- 
geny. 

We have seen that the mammal ovum is microscopic, and that the 
vitellary ball is thrust forth from the ovi capsule, seized upon by the 
Fallopian tube, and, as is supposed, deposited in the course of about 
eight days, in the cavity of the womb. By the time it reaches the 
womb it has acquired considerable additional volume, and very 
shortly aferwards is found to be a visible and palpable mass, already 
covered with its villi of the chorion, as in Velpeau's figure 1, repre- 
senting an ovum of eight or twelve days, in his first plate. 

Microscopy has not hitherto revealed a double coated capsule of the 
vitellary granules and corpuscles, but certainly only a few days elapse 
after the fecundation, before we may discover that the vitellary mem- 
brane, now become chorion, contains within it another vesicle or 
membrane called the amnion, in which is enclosed the embryo, with 
the waters and the cord. 

The heart of the embryo is early developed first as a straight pul- 
sating cylinder or artery which is afterwards bent, and finally con- 
verted by its morphological laws into the complex organ of the warm- 
blooded circulation. This heart drives the blood into the embryonal 
sarcode, wherein the blood makes its own channels, which, as they be- 
come complete, are blood-vessels. As the blood advances, the sub- 
stance is converted histologically, and becomes tissue, for "the blood 
is the fluid body? and the body the fixed and rigid blood," to reiterate 
the fine saying of Oken. Thus the blood creates the organs. 

Allantots. — Among other organs it creates the allantois. This is 
a small vesicle or bladder which rises from the pelvic extremity of the 
embryo, and springing forwards from the still open belly, proceeds be- 



PREGNANCY. 181 

twixt the outer chorion and the inner amnion, to enlarge and to attach 
itself to the chorion, carrying with it the blood-vessels which create it, 
and which are umbilical arteries which it applies by their distal extremes 
to the inner aspect of the chorion. This chorion they pierce, and goto 
seek an attachment, as placental tufts, to the inner wall of the womb. 
This bladder is the allantois. When the belly of the embryo becomes 
closed in, this bladder becomes strictured at the navel and in the trac- 
tus of the umbilical cord. The narrow strictured part of the vesicle is 
now a long cylindrical tube. The part retained within the now closed 
abdomen is the bladder of urine; the long cylindrical part is the ura- 
chus, and the outer expanded, or, to speak correctly, uncompressed and 
unstrictured portion is the allantois. The urine secreted in the kidney 
passes by ureters into the bladder of urine, and in the early stages of 
uterine life flows through the urachus into the bag of the allantois. 
Thus the allantois maybe said to be a bladder or vesicle, upon which 
the umbilical arteries climb towards the wall of the womb to attach 
themselves there. The word allantois should, according to Kraus, in 
his Lexicon, be allantodes. Its Latin equivalent is farcimen, of 
which the English translation is sausage, or gut-pudding. The ear- 
liest description of it was given by Galen, who evidently took it from 
the investigation of the ovum of the ruminants, in whose horned 
womb the allantois is a remarkable and most obvious organ which 
lines the interior of the whole chorion, and passes through or pierces 
its two ends to go to fill up the cornu as far as possible. No more 
correct description can be found of it than in M. Flourens' Cours 
sur la Generation. 

By many its existence in the human ovum is wholly denied; yet 
it. is asserted that in very early stages of foetal existence, injections 
into the urinary bladder of the embryo can pass along a urachus in 
the cord and go to be effused betwixt the amnion and the chorion : 
certainly it is by no means demonstrable in any advanced state of 
human pregnancy, as the Student will experience whenever he shall 
have an opportunity to dissect the aborted ovum, or inquire into the 
appearances of the secundines thrown off in an easy natural labor. 

Umbilical Vesicle. — The human yelk, as I said, is a microscopic 
globule filled with vitellary corpuscles. When the blastoderm has 
partly undergone the morphological change that converts it into the 
earliest rudimental embryon, part of the yelk corpuscles still remain 
unappropriated; and, as they are still contained in their original vitel- 
line membrane, they constitute a small but visible ball called the urn- 



182 



PREGNANCY. 



bilical vesicle. This vesicle opens into the intestinum ileum of the 
embryo by means of a long pipe or tube called the omphalo-mesenteric 
duct or vitelline duct. Velpeau says that the yelk matter contained 
in the umbilical vesicle can be pressed along the tube and through it 
squeezed into the gut. It is supposed to furnish a pabulum to the 
early embryo, but is lost after the fourth month ; for, by that time the 
amnion has grown so considerably as to fill up completely the cavity 
of the chorion; wherefore the umbilical vesicle being squeezed flat 
betwixt the amnion and chorion, finally disappears, becoming of no 
functional value when the child has completely established its 
branchio-absorptive connection with the parent. 



Omphalo-Mesenteric Vessels and Cord. — In perfect ova, aborted 
at the period of two months, or a little later, the Student will rea- 
dily distinguish the umbilical vesicle shining through the chorion 
and lying betwixt it and the delicate amniotic membrane. I add 
here a figure that may serve to explain its arrangement. Let a 
be a portion of the abdomen of the embryo, and c c the navel or 
umbilical ring; b b the navel string or cord laid open; d the umbi- 
lical vein bringing back the blood from the placenta and passing 

Fig, 60. 



L-^j 




'-<f. 



into the belly at the ring to go to the liver; ef the two umbilical arte- 
ries of the foetus; h the umbilical vesicle or vitelline sac whose pipe, 
conduit or efferent ducti runs along the umbilical cord to the navel, and 
passing into the belly empties itself in the ileum g g, which bends up 
to receive its discharge ; k I represents the omphalo-mesenteric vessels. 



PREGNANCY. 183 

In very early states the knuckle of intestine rises quite high up in 
the root of the umbilical cord — occasionally it becomes fixed there, 
and the child, continuing to grow, is at length born with an irre- 
ducible exomphalos. A careless accoucheur may, in cutting the navel 
string, have the misfortune to cut off the top of the arc of intestine 
and thus subject the miserable neonatus to the disgusting possession 
of an artificial anus, as happened in a case within my knowledge. 
I have seen the major part of the convolutions of the small intestines 
detained in an immense exomphalic tumor, covered only by the cord 
and a lining of peritoneum to which they irreducibly adhered. As 
the cord is essentially deciduous, no hope is left to save a child thus 
deformed. 

Now, as the umbilical cord is lined externally with amnion, it is 
clear that the umbilical vesicle lies outside of the amnion and inside 
of the chorion — a space which, perhaps, might be properly called the 
allantoidal space. 

There is no doubt of the normal existence of this allantois or allan- 
todes for the birds and the mammiferous quadrupeds, but as to man 
it is much questioned, and as I have said above, it cannot be demon- 
strated that there is a sac that may be dissected out, existing betwixt 
the amnion and chorion. Noortwyck's fine dissertation upon it to- 
wards the end of his volume, "Uteri Humani Gravidi Anatome et 
Historia" 4to. 1743. appears to me to settle the question: in his cri- 
ticism on Walter Needham's views of the sac, Noortwyck shows that 
it is indifferent whether there be a sac or no, for the space between 
the chorion and amnion is to all intents and purposes a true and suf- 
ficient allantois, one in which the urine of the early foetus can be dis- 
charged, as it is well known to be in the allantois of the bird, in w r hich 
urinous concretions may be found. 

After all, the Student may rest satisfied upon the point in so far as 
to understand that an allantois is a urinary bladder constricted in the 
middle like an hour-glass, the narrow neck being the urachus, the 
interior sac being the ordinary bladder of urine, and the one lying 
betwixt the chorion and amnion the real allantois. 

The embryo has now established its connection with the parent, it 
has surrounded itself with its amniotic membrane, which fills with the 
liquor amnii in which the new being is suspended. 

As its umbilical cord comes out of the abdomen nearest the pelvic 
extremity of the embryo, it hangs suspended with its head downwards 
whenever the woman is in a sitting or standing posture. It is true 
that the cord lengthens daily, and sometimes attains the length of six 



184 PREGNANCY. 

feet, although inclosed in a womb never more than twelve inches long. 
With such a great length, or even with a cord of eighteen inches long, 
it can no longer be said to be suspended; still the cephalic extremity 
of it falls to the lowest place, and the foetus as well as the embryo 
directs its head to the os uteri — it presents its head to the os uteri 
during; the utero-gestation as well as in labor. 

Circulation. — The circulation of the foetus is peculiar to it, and its 
continuance after birth is inconsistent with its respiratory life. If, 
therefore, the foetal circulation does not give place to the respiratory 
circulation, the neonatus perishes. This often happens. It is equally 
true, on the other hand, that if the foetal characteristics as to the cir- 
culation are lost before its birth, it is of necessity born dead. 

Let us inquire into the nature of the foetal circulation. 

The heart of the child in utero has four cavities — viz., a right and 
a left auricle, and a right and a left ventricle. 

An opening in the septum auricularum, which is called the foramen 
ovale or Botalli's foramen, and which on the left side of the septum is 
covered by a light floating valve, the valve of the foramen of Botalli, 
virtually converts these two chambers into one, as two apartments 
are thrown into one by opening a wide door between them. 

The left ventricle gives origin to the aorta. The right ventricle 
gives origin to the pulmonary artery. But, to speak rigorously, the 
pulmonary artery does not exist in the very beginning; for that which 
is called pulmonary artery is, in truth, the ductus arteriosus, from 
which the pulmonary artery arises at a more advanced period of ges- 
tation. Seeing that this is the case, and inasmuch as the ductus ar- 
teriosus joins the aorta below the arch, it is apparent that, when the 
right and left ventricles contract, simultaneously, they concur by 
their united power to drive the blood along the tube of the aorta — and 
this combination of the force of both the ventricles is perhaps requisite 
to propel, not only the blood that circulates within the limits of the 
child's body, but also that which it sends far beyond those limits to 
take up plasma and oxygen in the placental tufts, at the distance, 
sometimes, of six feet and generally not less than twenty-four inches 
from the systolic source. Thus it is seen that the foetal heart, though 
divided like that of the breathing warm-blooded mammal, into four 
distinct chambers, is, by means of the foramen of Botalli and the duc- 
tus arteriosus, reduced back, in fact, to the condition of the fish's 
heart, which has but two cavities, one auricle, and one ventricle, 
while the placenta, which is its branchial organ of aeration, takes up 



PREGNANCY. 185 

like the gills or branchia of the fish, the oxygen it finds in the medium 
in which it exists. Thus the heart employs the strength of both its 
ventricles to carry on such an exaggerated circulation. 

There can nowhere be discovered a more admirable adaptation of 
a simple machinery to produce compound results than in that of the 
foetal circulation; for, by the arrangement above mentioned, the single 
tube of the aorta is capable of effecting the double purpose of con- 
ducting the aerated blood to the tissues, to oxygenate them ; and of 
carrying back the carbonated blood to the placenta. The aorta, in this 
sense, is at once an oxygeniferous and a carboniferous tube. For, 
be it understood, the blood, when endowed with oxygen in the pla- 
centa, returns along the umbilical vein to the navel, whence, running 
at the edge of the falciform ligament of the liver, it enters the great 
fissure and divides, part of the fluid entering into the left portal 
vein, and the rest continuing its course through the ductus venosus, 
which delivers it into the left hepatic vein, which pours it into the 
lower cava. From the cava it enters the lower, right, posterior part 
of the right auricle behind the curtain-like valve of Eustachi, which 
conducts it across the posterior part of the auricle to the foramen of 
Botalli. Here, the current lifts the valve on the left side of the septum 
auricularum to fill the left auricle. The auricle, being full, contracts, 
and pushes it into the left ventricle, whose next contraction injects it 
into the aorta. Thus the blood of the placenta reaches the aorta. 
Much of it is now determined to the brain and the superior extremities ; 
the rest, turning through the aortic arch, is distributed in all the 
branches of that great trunk, a portion going back to the placenta 
again. 

This is the systemic circulation of the foetus. 

That portion of the placental blood which passes into the carotids 
and subclavians, gives up in their capillaries its oxygen and part of its 
substance, to the brain and upper limbs. It is next found in the 
veins, and returns to the right auricle by the route of the superior 
cava, which delivers it into the top of the auricle in front of Eustachi's 
valve, and opposite to the iter ad ventriculum dextrum, which gapes 
to receive and ingurgitate it. As soon as the right ventricle becomes 
filled, its contraction takes place, and this black blood, or venous 
blood, or carboniferous blood, is injected into the ductus arteriosus, 
which pours it into the aorta below the giving off of the left subcla- 
vian, thus precluding the possibility of its return to the brain, where 
its carboniferous nature would make it fatal, by the superinduction of 
asphyxia; because, asphyxia is black blood in the brain. 



186 PREGNANCY. 

The venous blood that has thus returned from the encephalon and arms 
is by this beautiful arrangement carried with due precision back to the 
placental tufts ; where, renewing its endowment of oxygen, it becomes 
fitted again to circulate in all the system of the child. By this curious 
arrangement of the cavities and opercula of the heart, there is a cross^ 
ing of the currents of red and black blood in the right auricle, the red 
blood running horizontally across the posterior part of the auricle, and 
the black blood falling perpendicularly downwards from the aperture 
of the superior cava, into the iter ad ventriculum dextrum. Doubt- 
less the valve of Eustachi contributes much to the perfect operation of 
this mechanism. 

The branchial apparatus above described, suffices in air the mam- 
mals and birds to communicate to the constitution of the. embryo the 
requisite amount of oxygen ; but it ought to be observed that that 
amount is small, indeed, compared with the freeness of the endowment 
vouchsafed to a state of respiratory existence. The embryo requires no 
more than what suffices to oxygenate its fluids and solids to the extent 
of provoking an active nutrition and impart a power of gentle and rare 
muscular motion — for the foetus in utero may be regarded as torpid, 
and as approaching in torpidity to the state of the hybernating animals. 
To cut off even this slender supply is to ensure its destruction. Now, 
inasmuch as the placental blood, entering in at the umbilicus, passing 
by the ductus venosus to the inferior cava, along that tube to the au- 
ricle, and through the foramen Botalli to the left auricle, left ventricle, 
aorta, carotids and vertebrals to the brain, takes the only possible 
route from the placenta to the brain ; it is clear that if, before the 
birth, the foramen ovale should be closed, no oxygen could possibly 
reach the brain ; but oxygen in the brain is essential to the evolution 
of biotic force. When, therefore, no oxygen reaches the brain, the 
brain evolves no nerve force, and the patient being asphyxiated dies. 
The law, then, is that the foetus is born with an open foramen ovale, 
which becomes closed after birth, generally within three or four days, 
often in ten or twelve days, not rarely about the twentieth day, and 
sometimes never. 

I have said that the child's foramen Botalli remains open during 
the whole uterine life; but the Student ought to observe that it is al- 
ways covered by its valve, lying upon the left side of the septum — a 
valve so light and delicate as to be transparent, and so beautifully 
arranged as to enable it to cover the operculum in the most perfect 
manner. The weight of a drop of blood, resting on its right side, 
might lift, as a drop on its left surface might shut it down. The nor- 



PREGNANCY. 187 

mal direction of the current through the foramen, keeps it open in the 
foetal heart. When, therefore, after the child is born, the two auricles 
act at the same time, in equal times and with the same intensity, the 
valve is pressed upon the operculum to cut off the foetal route, and com- 
pel the whole of the right auricular torrent to pass to the right ventricle. 
If the left auricle should be the strongest, the earliest, and the longest 
to contract, it is impossible that any black blood should come into it. 
If, on the other hand, the right auricle should, after the birth, con- 
tract sooner, longer, and more energetically than the left, the valve 
of Botalli would be lifted, and the black blood of the venous system, 
instead of returning by the pulmonary ventricle and artery to the 
lungs, would pass to the left auricle, ventricle, and aorta to inundate 
the neurine of the brain with its carboniferous stream, which, wholly 
incapable of exciting any biotic force in the brain, would be cyanosis 
— asphyxia — death. When the nervous mass ceases to act, the whole 
constitution is dead. It always ceases to act where there is no oxygen. 

The Student will now understand that when the child is born at 
full term, its peculiarities, as to the heart, remain for some time un- 
changed ; and he will be able to appreciate certain conditions of the 
neonatus dependent upon the continuance, partially, of the foetal cir- 
culation — a circulation, in w T hich the aeration of the blood is of so low 
a grade that it cannot supply the demand for the more violent ener- 
gies of the respiratory life. 

Children are sometimes born dead without any known cause. It is 
probable that, in some of the instances, death has taken place in con- 
sequence of the too rapid progress of the development of the heart, 
which, hastening to reduce its foetal openings to the smallest diameter 
consistent with intra-uterine life, urges the reduction of the opercula 
beyond the legitimate bounds, and thus renders death inevitable by 
cutting off a part of the already scanty supply of oxygen to the 
neurine. 

If, in its gyrations within the w 7 omb, the child should enter a coil 
of the navel-string, and passing through it, should thus make a knot 
on the cord — that knot, happening to be strongly drawn, might cause 
its death by hindering the complete return of the blood of the placenta. 
Sometimes two, or even three such knots are found on the cord. I 
delivered a lady here of a very fine child which was dead-born, ap- 
parently, from the closeness with which the navel-string knot was 
tied. It is true, however, that w r e meet with very healthy and vigor- 
ous children, notwithstanding the presence of one, or more than one 
of these knots on the cord. 



188 



PREGNANCY. 



As pressure on the cord, and obstruction to the course of the blood 
in it, may cut off the foetus in utero, it is evident that where the same 
cord prolapses in a labor, it may be fatally pinched betwixt the bony 
head of the infant and the osseous wall of the pelvis — nay, the resist- 
ance of the os uteri, vagina, and orificium vagina?, may suffice fatally 
to compress it. Of this, however, we shall speak in another page. 

The child in utero is liable to a great variety of diseases, and to 
accidental complications of structure that exert a very unhappy in- 
fluence upon the labor. Thus it happens that the encephalon becomes 
the seat of a dropsical effusion, which renders the size of the head so 
vast as to make its transit through the pelvis impossible, until, by an 
embryulcia, the hydrencephalic fluid shall have been discharged. 

In like manner, vast collections of water in the abdomen constitut- 
ing ascites of the foetus may render the belly so large that the child 
cannot be born until it shall first have been tapped, which may be 
readily done with the long trocar, described by me in a future page, 
or by means of Holme's perforator, in cases where the signs of the 
death of the foetus are absolutety undeniable. 

It is proper that the Student should be made aware, that some of 
these great watery swellings of the belly of the foetus have, upon exa- 
mination, been discovered to be cases of retentio urinaB. The urinary 
bladder of the child has been known to rise as high as the scrobicu- 
lus cordis, and distend the belly like an enormous ascites, in conse- 
quence of obstruction or atresia of the urethra. The treatment of 
such a case, of which the diagnosis, before its delivery, is impossible, 
is the same as for ascites — videlicet, the paracentesis abdominis — which 
reducing the swelling, allows the birth to be effected. 

In addition to the cases of disproportion effected by dropsical col- 
lections, there are instances of accidental disproportion resulting from 
the union of two foetuses in one. The celebrated example of the 
Siamese twins is familiar in the United States, and it is easy to con- 
ceive that such a union could not but render difficult and preternatural, 
a labor in which such should be born. 

The instances of children with two heads are not rare, numerous 
examples of them being contained in the books. The example that 
has been so admirably described by M. Serres, in his Anatomie Trans- 
cendente, appears to me to be particularly worthy the student's atten- 
tion. This monster was born at Sassari, in the kingdom of Sardinia, 
in the year 1829. There were two heads, a double thorax, with four 
arms, and one abdomen, with two legs. Being christened, the one 
on the right took the name of Rita, and the left one that of Christina. 



PREGNANCY. 



189 



Fig. 61. 



Rita-Christina was brought to Paris and exhibited there, until death 
closed its exhibition when the monster had attained the age of eight- 
een months. I subjoin a figure which represents a case of double- 
headed foetus, born in Adams County, Penna., in 1844, under the 
medical care of Dr. Pfeiffer, a German physician in practice there, 
who brought the monster to this city. I engaged Mr. Neagle, one of 
our best artists, to paint a portrait of it, from which this small cut is 
taken, and represents it very correctly. 

In this figure it is seen that the mon- 
ster possessed only a right and a left 
arm, whereas Rita-Christina had four 
arms, because in her case, the cervical, 
dorsal, and lumbar vertebrae were com- 
plete for each child ; whereas in this 
sample, the cervical and dorsal vertebrae 
only of each child were complete, while 
they united in a common or single lum- 
bar spine, and one pelvis. Rita and 
Christina each had its own ribs, and a 
sternum for each, yet admitting of a 
single thoracic cavity for two hearts, and 
only two lungs. The liver was a com- 
pound of two livers; there were two 
stomachs, two duodenums, jejunums, 
and two ileums, uniting towards their 
lower extremities, into a single short 
ileum, inserted into a single csecum. 
There was but one colon and one rec- 
tum, and one bladder of urine. ' 

There is, in my collection, a specimen, consisting of two children 
united by the ileum intestine, which comes out from the navel of each 
child covered by the umbilical cord. The two cords, midway betwixt 
the children, merge into a single umbilical cord, inserted into one 
placenta. This specimen was presented to me by Dr. Clarke, of 
Philadelphia County. The children are separated by the omphalody- 
mic cord about four inches; and there are tw^o apertures in the cord, 
each of w T hich is an accidental anus, from which the meconium 
escaped freely. There are also two apertures from which flow T s the 
urine produced by both children. There are many cases to be met 
with, of children with only one head, yet possessing two bodies and 




190 



PREGNANCY. 



tour legs; and some, in which the heads are united at the summit, or 
crown. 

Here is a portrait of a foetus that was shown to me by Dr. Rohrer, 
of this city, soon after its birth under his professional care. 

Fig. 62. 




The great tumor in the vertex consisted of scalp lined with the ordi- 
nary encephalic meninges, and filled with the water of a vast dropsy 
of the brain. The posterior part of the parietal and occipital bones 
was wanting ; some hairs grew on the part of the tumor near the vertex ; 
the rest was bald. The child was in other respects well formed, and 
very large. The tumor was soft and fluctuating, but not reducible in 
size by pressure in the hands. Its greatest length was nine inches. I 
shall refer hereafter to this figure, to that of the double-headed monster 
of Dr. PfeifTer, and to Rita-Christina, to show the necessity and nature 
of what is in Midwifery called Evolution of the foetus. Observations 
on the midwifery of the case would be out of place on this page. 

M. Serres' work, and that of M. G. de St. Hilaire, exhibit a great 
variety of Teratological foetuses, to which I must merely allude, as 
the limits of this volume will admit of no extended observations upon 
them. 

I have mentioned them here, chiefly with the view to put the Student 
on his guard, as to the midwifery of such cases, and still more in 



PREGNANCY. 191 

order that he may early learn that these monsters are merely results, 
not of excess, but of failure in development. The double-headed 
foetus, Fig. 61, has two stomachs, and probably two hearts, but only 
one intestinal canal, composed by the union of the two jejunums, or 
the two ileums, into a single jejunum or ileum, a colon and rectum. 
This child is a twin, which has not acquired a superfluous head, but 
which has lost, one a left, and the other a right arm ; one the right, 
and the other the left half of its thorax — one kidney — half its colon 
and rectum, bladder, testes and penis, a right or a left leg. 

This double-headed foetus then has lost, not gained : it has been 
fused, or, to use a term in mechanics, welded. The right child has 
sunk part of its body in that of the left child, which in like manner 
has sunk the right half of its body in the left half of its twin brother. 
In Rita-Christina, if both children happened to be asleep, and one 
should tickle Rita's foot, she would wake and smile; so, if Christina's 
foot were tickled, it would cause her to laugh, without at all affecting 
her sister, for the left leg was Christina's and not Rita's, and vice 
versa. 

Happily, when twins are conceived, they inhabit each its own 
amnion, and in some instances, its own chorion ; which insulates them. 
When the development of the amnion fails, and the two germinal 
membranes are brought into contact, they may unite, or weld together, 
under a certain law; but the back of one cannot unite to the abdomen 
of the other, nor the head of one child to the other's pelvis. In order 
to unite, only the edges of the still "unclosed germinal membrane can 
weld — that is, the left edge of one with the right edge of the other, 
and mutatis mutandis. Hence the law of development is binding; 
that law ordains that the right edge of the membrane, when bent 
over to shut in the trunk, should unite w r ith the left edge turned in- 
wards in like manner. 

If we might suppose the germinal area of the germinal membrane 
to be in shape a long oval, like Fig. 63, and a the 
cephalic pole, b the pelvic pole ; c d the brachial, and g " 63 ' 

efthe crural regions; we may conceive that no sub- 
lunary power could develop a pelvis at a, or a head at 
b ; a leg at c d, or an arm at e f\ for even in this mi- 
croscopic mass the generic law is as imperative and 
coercive as the attraction of gravitation is for the whole 
earth. There is nothing generically in common or 
identical in a and 6, or in c d and ef; c unites with d 
only, and e withy* only; when the scaphoidal germinal 
membrane has become completely bent into the appo- 



^ 




192 



PREGNANCY. 



Fig. 64. 




sition of the edges c e and d f to make the cavity of the belly and tho- 
rax, d could not unite with e nor c withy. 

If in the adjoined diagram, Fig. 64, the two ovals may represent the 
germinal area of twins, then a and I may 
unite if brought into apposition, or 6 and m; 
c and g and e and i have no affinity. If c 
and g which have affinity should unite, the 
result would be a foetus with one head, 
two arms and four legs ; if e and k,f and 
i be placed in contact in utero, their affini- 
ty would cost a left leg for the right hand 
membrane, and a right leg for that on the 
left. Thus we should have a Rita-Chris- 
tina. It is a curious subject of reflection, 
that of the individuality or duality of a 
creature with one head and two bodies, or with two heads and one 
body. Rita-Christina was dual, as was Dr. Pfeiffer's monster, Fig. 61, 
but as to the monster figured in Serres' Plate 12, it is to be doubted 
whether the personal identity was absolute or no — as there was one 
common cerebellum. 

Doubtless, it is not possible, in Teratology, to suppose that half of 
one child should sink into and be totally lost in half of another child, 
thus making out of two independent personal identities a single one. 
In nature, the union must take place from the liver upwards only, or 
from the liver downwards only; whence, it cannot happen that the 
whole right symmetrical half of the left twin should be sunk in the 
left symmetrical half of the right twin. We may therefore expect to 
meet with cephalodym or hepatodym or pelvidym, and not with 
such a union of two personal identities as would be to fulfil the 
ancient fable of the union of Salmacis and her lover. 

All such fusions imply loss, not gain of substance ; or monstrosity by 
default, and not monstrosity by excess. If a child is born with six 
fingers on either or each hand, or six toes on either or each foot, it 
presents a case of excess of development or monstrosity by excess ; 
and the samples of five-legged calves, &c, that are commonly met 
with, are cases of monstrosity by excess. 

There was a singular example of cephalodym here some four years 
ago: it was a healthy pig with one head, two fore legs, and two 
bodies, with four hind legs. It was a remarkable fact that the geni- 
talia of this creature were not ruled by a common influence of its 
nervous system; when the animal was in heat, it was either as to the 



PREGNANCY. 



193 



genitalia of the right or those of the left trunk ; but they were not 
observed to be in heat or rut at the same time, one trunk appearing to 
become the subject of the periodical excitement about ten days after 
the other had ceased to be so. What was the condition of personal 
identity in this monster ! 

The instances of monstrosity by default of development are suffi- 
ciently numerous; as, for example, in the cases of spina bifida, of 
anencephalous and acephalous foetuses, and of foetuses with imperfect 
iimbs ; and those with imperforation of the rectum and other atresias. 

The Student will have little trouble to understand and explain these 
strange freaks of nature, if, in all cases, he will remember that the 
monstrosity is dependent upon fusion of the parts of two different chil- 
dren, or on a cessation, during the embryonal stage of life, of that 
growth and progress which, 

but for the arrestation, Flg - 65 - 

would have finished and 
rendered complete, parts 
that now exhibit the ap- 
pearance of the most shock- 
ing deformity. 

We meet with numerous 
cases of ectopy; cases in 
which organs or parts are 
displaced or deviated. — 
Here, in Fig. 65, is the 
figure of a child lately born 
under my care. It lived 
for several days. The 
tumor on its belly is an ex- 
omphalos, consisting of the 
entire liver of the infant, 
which was contained within 
the root of the umbilical 
cord. There was no cover- 
ing of this liver save the 
deciduous matter of the 

cord. Of course when the cord should fall after five or ten days, the 
liver would be wholly exposed. Such an accident renders the child 
absolutely non-viable. 




Duration of Pregnancy. — The duration of gestation is ordinarily 
13 



194 PREGNANCY. 

computed to be nine months or 280 days; and the Women, who un- 
derstand these questions by a traditionary learning, commonly make 
their calculations with sufficient accuracy. 

According to the Civil code in France, a pregnancy may properly 
be held to continue until the 300th day ; which is allowing a latitude 
of twenty days beyond term. I have been surprised to find how preva- 
lent has been in all ages the opinion that a great latitude exists as to 
the duration of pregnancy, and that the ablest men of our profession, 
both ancient, mediaeval, and modern, have admitted a latitude far 
greater than that allowed in the French code. I rejoice that this is 
the case, because, having myself had reason to believe that pregnancy 
may endure even beyond twelve months, as I shall relate in another 
page, I conceive it desirable that the truth should be established for 
the conservation of the credit and peace of those persons or families 
in which such extraordinary postponement of the term might give rise 
to the greatest injustice, as well as unhappiness. 

It would seem that the most common and ordinary observations and 
proofs are incapable of expelling from the public mind opinions that 
have been long established, upon whatever foundation, however un- 
substantial. There is hardly to be found any old wife in the country, 
who does not know that the term of incubation of the barn-door fowl is 
uncertain ; and that though it ordinarily lasts twenty-one days, the 
chick is found to escape from its shell on the twentieth, or to linger 
in it, sometimes, to the twenty-second or twenty-third day. Similar 
facts as regards the gestation of our domestic quadrupeds are abundant, 
and sufficient to demonstrate the latitudinarian character of what is 
called term. To show the differences in gestation, I subjoin the fol- 
lowing tables which I find in M. Rainard, Traite complet de la Partu- 
rition des principales Femelles Domestiques, torn. i. p. 233 et seq. 

Simon Winter was the first to collect accurate accounts on this sub- 
ject. The date of the Covering was noted as to fifteen mares, of which 
eight foaled after 340 days, three after 342 days, three after 343 
days, and only one at 346 days. 

Brugnone, in like manner, in fifty-five mares found that the foaling 
took place in 

1 in 10 months less 7 days 

1 " 11 " " 1 day 

2 " 330 days 
2 " 333 " 
2 " 334 " 
2 " 335 « 



4 


in 


336 


days 


2 


a 


337 


a 


2 


ii 


338 


ii 


1 


ii 


339 


a 


3 


ii 


340 


a 


1 


ii 


341 


a 



3 in 342 


days 


2 in 351 


JLC7. 

days 


5 " 343 


a 


2 " 352 


a 


2 " 344 


a 


1 " 353 


a 


3 " 345 


a 


1 " 356 


a 


4 " 346 


a 


1 " 357 


iC 


4 " 347 


a 


1 " 369 


a 


1 " 348 


a 


1 « 389 


" or 13 months 



" The difference between the most precocious and the most pro- 
tracted gestation amounts to seventy-seven days, or two months and 
a half. From his table, Brugnone concludes that gestation is not com- 
plete in less than one year, and that when it goes beyond that term, 
there is no fixed period. " — P. 233. 

M. Tessier found that in the gestation of 200 mares, there was a 
latitude of eighty-three days. — P. 239. 

The Journal aVEconomie rurale Beige, 1829, finds a minimum of 
322 days, a mean of 347 days, and a maximum term of 419 days; 
difference, ninety-seven days. — P. 234. 

M. Grille's statement, Mem. de la Societe Industrielle d? Angers, 
No. 2, ll e annee, p. 55, shows in 114 mares a difference in gesta- 
tion of ninety-three days. — P. 239. 

The observations made by order of Earl Spencer, as to the gestation 
of 764 cows, show that the shortest period of gestation is 220 days, 
though the ordinary duration is of 284 or 285 days. — P. 235. 

Among sixty-five sows, two littered on the 104th day; ten from the 
110th to the 115th; twenty-three from the 115th to the 120th; 
twenty-seven from the 120th to the 125th; two on the 126th, and one 
on the 127th day. This is a latitude of twenty-three days. 

M. Rainard further gives, from the Bulletin de la Societe Industrielle 
d' Angers, the following statement of the duration of gestation in 154 
rabbits, viz : 1 littered on the 27th day, 7 from the 28th to the 29th ; 
53 on the 30th; 61 on the 31st ; and 29 from the 32d to the 34th day. 

These statements show with sufficient clearness that the duration of 
gestation is by no means a fixed term in any of the genera, and I should 
suppose that the least reflection might lead us to the same conclusion, 
since the nature of the womb, as well as that of the child, is such as to 
render it impossible that the laws that govern the contractility of the 
one or the rate of development of the other, should operate in all cases 
in equal times. The womb of one individual, as well as the fetus 
within it, may be ready for the act of parturition earlier or later, accord- 
ing to the force of a variety of causes to the operation of which they 
are liable. 



196 PREGNANCY. 

Professor Asdrubali, in his account of the thirteen months' gestation 
of the Signora N., cites the following passage from Spigelius, who, in 
speaking of the causes of labor, or of the completion of pregnancy, 
says, "Haec nulla alia esse potest, quam maturatio, et perfectio foetus, 
quae fit in ut'ero incerto tempore et variis interdum mensi- 
bus, ob facultates corpus foetus gubernantes vel debiliores vel robus- 
tiores." 

The same author, Asdrubali, in his Trattato Generate di Ostetricia 
Teoretica e Pratica, torn, v., gives us a succinct relation of the preg- 
nancy and confinement of the lady, the Signora N., who carried twins 
in the womb over thirteen months. 

Probably so great an extension of the uterine life of the foetuses 
may excite the reader to surprise, and even to a denial of the facts of 
that case. But I should think that that elegant and learned Scholar, 
who gives us the history of the pregnancy, ought to be held worthy of 
our confidence ; and I believe it would be difficult to read his fifth vol- 
ume, which is devoted to the examination of the subject of protracted 
pregnancy, without being convinced, not only of the sincerity, but of 
the truthfulness of the author. 

Case. — The lady, aged 26 years, was married on the 15th of April, 
1793. She became pregnant in March, 1795, after having been mar- 
ried 21 months. The child, which was born in December of the same 
year, died on the 8th day. About the 1st of March, 1796, she was af- 
fected with symptoms which induced her to supposes he had again con- 
ceived. On the 13th of the same month she removed to a neighbor- 
ing district. Upon returning to her residence, she was shocked to find 
her husband, a nobleman, ill with a disease of which he died on the 
22d of the same month. To the grief occasioned by the loss of her 
spouse were added great distress and embarrassment connected with 
the inheritance of his estate, and notwithstanding she early declared 
the existence of her pregnancy, she was much tormented and baffled by 
his relatives, who treated her declaration as false. At the beginning 
of the fourth month of gestation, she perceived the quickening in the 
womb. Throughout the fifth and part of the sixth month, the move- 
ment in the womb was so violent as to have the appearance of con- 
stant convulsive action. Towards the end of the sixth month the 
motion almost wholly ceased. The abdomen appeared to be cold ; 
the breasts became hard, and there was a discharge resembling whey 
from the nipples. It w T as about this time that her family quarrels, 
insults, and disappointments became most aggravated, and in this 



PREGNANCY. 197 

condition she concluded the sixth, seventh, and eighth months. At 
the commencement of the ninth month she was seized with pains like 
labor-pains, and discharged from the womb a great quantity of watery 
fluid. The pains continued to recur during eight consecutive days. 
They now ceased, as well as the watery discharges, and the lady 
again began to feel the motions of the fruit of the womb, while the 
lower belly again recovered its feeling of warmth. The abdomen, 
which had ceased to grow, now resumed its process of development. 
The breasts ceased to flow, and became flaccid. During the tenth 
and eleventh months she experienced a sense of weight in the hypo- 
gaster, and had difficulty and pain in the act of urinating. In the 
course of the twelfth and thirteenth months she was assailed, first 
every eight and then every fifteen days, with pains like those she had 
felt in the beginning of the ninth month. These pains lasted some- 
times four and sometimes five hours alternately. On the 22d of April, 
1797, she was attacked with symptoms of labor, and on the 29th gave 
birth to twins. 

Such is a compendious relation of the case of which the particulars 
are given in long detail by Prof. Asdrubali. I lay it before the Student 
with the assurance that I cordially accept the story of the accomplished 
author, and that, notwithstanding it presents a rare example of pro- 
crastination of the Term, I find in it nothing impossible to believe; the 
more particularly as I have confidence in the correctness of the fol- 
lowing statement of a case that fell under my own clinical care. 

Case. — Saturday, August 1 , 1840. Being at the Pennsylvania Hos- 
pital, a lady came to me and requested that, as a medical officer of the 
House, I would see Ann Gideon, in Clarke street, Southwark, in order 
to her admission into the Lying-in ward. I was told that her con- 
finement, which had been looked for in April, had not yet taken place, 
that she was suffering under the effects of this unnatural pregnancy, 
and that the neighbors thought she ought to receive the cares of the 
Institution. Upon proceeding to Clarke street, I learned that she was 
twenty-six years of age, that she had been confined on the 18th of 
February, 1839, in the Pennsylvania Hospital, and was again pregnant 
in the month of July, 1839, while suckling her son. Being very much 
indisposed, she called a physician, who directed her to wean the child, 
as she was doubtless pregnant. She did not, however, wean him until 
September, when she felt sure of her pregnancy. On the 20th of No- 
vember she quickened, and her husband very distinctly perceived the 
motion of the child at Christmas. On or about the 10th day of April, 



198 PREGNANCY." 

1840, being very large and lusty, she was taken in the night with the 
symptoms of labor, and called in her neighbors. The waters broke in 
the night and wetted her profusely. After the rupture of the membranes 
the pains were great, and she supposed the child would be soon born ; 
but as the pains not long afterwards grew easier, she did not send for 
the doctor till morning; at that time they had become much less dis- 
tressing ; in short, they gradually left her : but she continued big, and 
could daily, and even now, feel the child when it moved, which gave 
her great pain. 

She was laboring under a very decided hectical fever and irritation, 
which had already very much reduced her flesh and health. She ob- 
tained but little sleep, and had a poor appetite. She daily suffered 
acute pains in the abdomen. She got a ticket for the Lying-in depart- 
ment, and came in on the 4th day of August. The os uteri was found 
to be not dilated, though the cervix was fully developed, having lost 
entirely its tubular or cylindrical form. The form of the abdominal 
tumor was conical, the umbilicus being at the apex of the cone. Two 
or three inches above the umbilicus was the commencement of an ob- 
long tumor, extending to within a very short distance of the xiphoid 
cartilage, and about three inches in width by two in height. This 
was a hernia produced by the separation of the linea alba, through 
which protruded a quantity of the intestine thinly covered and re- 
strained by the peritoneum and skin. 

She remained in the ward suffering daily and nightly with abdomi- 
nal pains until she fell into labor on the 11th of September, and the 
child was born on the 13th of September, about daylight. I sat up 
with her all night, being deeply interested to observe all the phe- 
nomena of the case. 

The child, a male, was of a medium size, weighing seven or eight 
pounds; in good health. The labor was extremely tedious, and dis- 
tressing. She had a pretty good getting up, but the hernia of the 
linea alba caused great weakness, which was in a measure relieved 
by a truss made expressly for her. She was discharged October 11th, 
1840. 

Of course, in relating this case, I do not consider myself responsible 
for the truth of its statements further than they are worthy of confidence 
in view of the character of the patient herself, and as the facts came 
under my notice. She had the appearance of perfect candor and sin- 
cerity in all that she said about it, and I have no doubt she thinks her 
pregnancy began in July, 1839, and ended, as I have said, on the 13th 
of September, 1840; having endured near fourteen months, or four 



PREGNANCY. 199 

hundred and twenty days, instead of two hundred and eighty, the 
usual term of a pregnancy. 

In July, 1841, she is pregnant again, and still suffers from the pro- 
trusion in the upper part of the linea alba. 

Dr. Merriman, of London, has published, in vol. xiii. part ii. of the 
London Medico- Chirurgical Transactions, a paper on the Period of 
Parturition, which contains an interesting table of the births of one 
hundred and fourteen mature children, calculated from, but not in- 
cluding, the day on which the catamenia were last distinguishable. 

By this table it appears that three were born in the thirty-seventh 
week, thirteen in the thirty-eighth week,. fourteen in the thirty-ninth 
week, thirty-three in the fortieth week, twenty-two in the forty-first 
week, fifteen in the forty-second week, ten in the forty-third week, 
and four in the forty-fourth week, of which latter, one was born at 
three hundred and three days, one at three hundred and five days, 
and two at three hundred and six days. 

Dr. Merriman states that he has calculated a great many more cases 
in the same manner, but has restricted his table to the above one hun- 
dred and fourteen cases, because he was able completely to verify 
them. The others gave results so nearly similar, that he has no doubt 
of the general correctness of the principle he desired to enforce, which 
was, that conception takes place, in general, soon after the cessation 
of the catamenial flow, and not just antecedently to its expected re- 
turn. The table is highly interesting, in the relations for which I 
would use it, showing, as it does fully, that there is a considerable 
latitude in the duration of gestation. 

Computation of Term. — The ordinary Term of a gestation is at- 
tained in about two hundred and eighty days, and it is customary 
among medical men to assign the two hundred and eightieth as the day 
on which the child may be expected to be born. In making the com- 
putation for my patients, my own habit has been, to inquire as to the 
day and date of the disappearance of the last menstrua; to commence 
the series on the day following the disappearance, and add two hun- 
dred and seventy-nine days to it. This mode has answered my pur- 
pose well enough, but it is clear that it would not answer for the 
calculation of term, in the case of a religious Jewess. 

That experienced practitioner, and most judicious author, Professor 
Nsegele, of Heidelberg, in his Lehrbuch der Geburtshuelfe, 8vo. 1842, in 
a remark at the foot of page 82, gives the following method of computing 
term. Let the woman reckon three months back from the day when 



200 PREGNANCY. 

her menses ceased, and to the said three months, let her add seven 
days. The day thus found, is the one on which she ought to expect 
her confinement. If, for example, she had her courses last on the 
10th of June, let her reckon backward three months, to March 10th, 
to which she should add seven days, which would bring the calculation 
to the 17th of March. This would be the day, to wit, March 17th, on 
which the woman ought to expect her lying-in. Such is the method 
of calculation recommended by Dr. Nsegele, and it must be admitted 
that no man in Europe enjoys a more enviable reputation as a teacher 
and practitioner in our art. One might feel safe in following his ex- 
ample in the practice of it. Still, I cannot perceive why the seven 
days should be added to the three months, or, rather, to the whole 
term, since the Professor gives no reason for us to suppose that the 
ovulum is not both mature and ready for fecundation, as soon as the 
catamenial flow has ceased, and the genitalia have recovered their 
fitness for the congress of the sexes. As I have no reason hitherto to 
find fault with my own method, I shall continue to compute from the 
day of cessation; so that, if my patient should inform me she saw 
the last stain on August 27th, I should reckon backwards to July 27th, 
June 27th, and May 27th, prox°., which day I should indicate as the one 
on which the labor might be expected to commence, and not June 3d. 

Changes in the Womb. — The form of the womb changes with the 
progress of pregnancy. The vaginal cervix grows shorter, and at 
length wholly loses its cylindrical, or tubular shape, leaving at the 
upper end of the vagina an orbicular or hemispherical protuberance 
with a dimple in its apex, which is the os tineas of the womb-at-term. 

As the ovum expands, it carries the uterus along with it, at first, 
making use of the cavity of the fundus and body of the organ, and 
only distending the upper part of the cervix in the first months of 
pregnancy ; so that, if an examination should be made of a woman 
three months pregnant, the tubulated cervix uteri would be found to 
have undergone very little perceptible shortening. 

The cervix certainly becomes fuller and larger, at a very early 
period of pregnancy, and presents, in this respect, a sensible differ- 
ence from its unimpregnated state. At the close of pregnancy, the 
cervix uteri seems to have wholly disappeared, and the womb, instead 
of exhibiting a tubulated or cylindrical neck, is become an oval, the 
os tincse being at the lowest end. No decided change in the length 
of the cylindrical part is discovered by the Touch, until after the fifth 
month, or, according to certain authorities, the seventh month. From 



PREGNANCY. 201 

that period it grows daily shorter, until the last days of gestation, when 
it is not to be discovered at all. A pregnant woman, therefore, in 
whom it has wholly disappeared, is said to be ready to commence the 
process of labor. The attack of labor pains may begin very soon 
after the disappearance of the cervix, or it may be deferred for seve- 

Fig. 66. 




ral days, from causes which are not understood. Figure 66 ex- 
hibits the form of the gravid uterus, which may be compared with that 
of the unimpregnated organ, Fig. 41. 

In all instances that have fallen under my notice, the thickness of 
the walls of the womb, when at term, has been rather less than in the 
non-gravid organ. The tissue is much looser and easier to cut, and 
yields to any distending force far more readily in the gravid, than in 
the non-gravid state. It is incomparably more vascular, so that in 
the last weeks of gestation, it may be compared to a purse, or net- 
work of blood-vessels, with an abundance of loose cellular tissue, and 
muscular fibres interspersed. The uterine arteries and veins which 
reach the womb near its lower extremity, inosculate freely with the 
ovarian or spermatic vessels, that enter its texture betwixt the folds 
of the broad ligaments, and supply the ovaria, the Fallopian tubes, 
and upper portions of the womb. The gravid womb at term is so 
richly supplied with circulation, that I have compared it to a vast 
aneurism-by-anastomosis, which offers to the acephalocyst the ovum, 
the most liberal sources of supply to its rapid accretions. 

Smellie, vol. ii. p. 19, says, that he had opportunities in 1747 and 
1748, of opening the bodies of two women who died at the full term 
of utero-gestation. The membranes were unruptured. They were 



202 PREGNANCY. 

each about a quarter of an inch thick. The same was the case with 
another specimen in his possession, which was in the eighth month of 
pregnancy. He had seen several others, in which the woman died 
soon after delivery, the womb not being much contracted, when the 
thickness of the walls was about the same as the above. Bat where 
the death did not occur for several days after delivery, and the womb 
was contracted, he found its parietes from one to two inches thick. 

Uterine Muscles. — With regard to the muscular structure of the 
womb, I shall remark that no person who has witnessed the exercise 
of it in labor, can doubt of its immense power, and particularly should 
he have felt it while the hand has been compressed by it, in turning a 
child in utero. Some years since, a gentleman of this city found him- 
self obliged to introduce his hand completely into the womb, in order 
to extract a retained placenta. While the hand was employed in 
separating the after-birth from the uterus, the os uteri closed upon his 
wrist with such force as to give him very severe pain, and he found it 
impossible to withdraw the hand, which was completely fastened by the 
contraction. After various unsuccessful attempts to extricate himself 
from such an unheard-of difficulty, he sent for a Bleeder, and after 
causing a large quantity of blood to be drawn from the lady's arm, the 
spasm of the cervix ceased, upon which he was liberated from an im- 
prisonment of two hours. His wrist was marked, as if a cord had been 
strongly bound round it ; the traces of which impression were visible, 
even the next day. 

The operation of turning the child, in a powerful womb, from which 
the waters have been entirely drained, not unfrequently produces a 
degree of numbness, from pressure, so great as to make it necessary 
to withdraw the one, and introduce the other hand; the sensibility 
and motion of the first one being wholly suspended. The resistance to 
be overcome in the expulsion of a grown foetus, requires a muscular 
force which cannot be exactly estimated, but which must be very 
great. 

Different writers describe the arrangement of the muscular fibres 
of the uterus in different manners. The very discrepancies of these 
authors ought to convince us that the arrangement is not well under- 
stood ; and, indeed, it is of no great consequence, in a practical view, 
that they should be demonstrated. It is enough to know that they 
are so arranged as to tend, by their combined contractions, to reduce 
the uterus back from the gravid size to that of the ud impregnated 
organ. When their contraction is co-ordinate, the fundus tends to 



PREGNANCY. 



203 



Fig. 67. 




approach the os tincae, and the sides tend to approach each other. 
Whatever is contained within the cavity of the organ is, under these 
circumstances, expelled therefrom. 

It should be always understood, that in speaking of the muscular 
structure of the womb, we speak of the gravid womb only, in which 
the arrangement and condition of 
those fibres are very different from 
those in the virgin or the non-gravid 
organ. Fig. 67 is a representation 
of their arrangements, proposed by 
M. Chailly, which differs from the 
very beautiful drawing of a dissec- 
tion of them, that is given in Dr. 
Moreau's Atlas. Both of them are 
unlike Madame Boivin's figure — 
and I have no doubt that every suc- 
cessive representation will differ 
from those that do, or may, precede 
it. My own attempts to extricate 

the tangled maze of muscular fibres leave me convinced that the only 
anatomy of them to be depended on, is the Transcendent anatomy — 
or that which is performed by the reason and not by the scalpel. 
He who has felt the womb contract upon his hand in a Caesarian ope- 
ration, or in repositing an inverted uterus after labor, or in extracting 
the placenta in hour-glass contraction, or in turning the child long 
after the waters are gone, will have a better conception of the muscu- 
larity and of the arrangement and distribution of the muscles than he 
who trusts to the dissecting knife alone. 

The action of the muscles of the womb ought, if normal, to be 
perfectly co-ordinate, all parts acting together, or at the same time. 
It is, however, true that in the state of contraction, all the parts do 
not always begin and cease to act at the same moment. 

Labor does not always proceed with regularity. The muscular 
power of the womb is occasionally found to be morbidly exercised. 
Those fibres that tend to bring the fundus near the os tincse, some- 
times fail to act, or act imperfectly ; while those that tend to approxi- 
mate the sides of the womb, act with such force as to compress the 
body of the foetus, and instead of expelling it, rather confine and 
retain it within the cavity. We frequently observe women to suffer 
under the most violent uterine pains, which nevertheless do not move 
the child downwards in the least degree : such pains should be sup- 



204 PREGXAXCY. 

pressed, if possible, in order :o admit of the co-ordinate and regular 
11 the fibres being resto: e d . after a temporary cessation 
or repose. It is such an action as this which constitutes the hour- 
glass contraction of the womb, which takes place in consequence of 
the non-separation of the placenta from the uterine surface — thus dis- 
abling that placento-uterine quarter from contracting equally with the 
rest of the orean. When this happens, the placenta is, of course, 
shut up within a cell, above the hour-glass contraction. 

Obliquity. — The gravid uterus commonly occupies the middle of 
the abdomen, in hale young women, notwithstanding both the projec- 
tion of the sacrum and the intrusion of the spinal column tend to give 
to it an oblique direction : hence, we generally find it to be inclined 
towards one ade :: the abdomen in persons of a lax and flaccid habit 
c : o dy. So far as my observation enables me to speak, it is oblique to 
the left more frequently than to the right side. 

Great degrees of obliquity are scarcely met with in first pregnan- 
cies, in consequence of the vigorous contractility of the abdominal 
muscles, which constrain the gravid womb to remain in the mesian 
line: whereas, in women who have borne many children, those mus- 
cles acquire such a laxity and want of tone as to allow the organ to 
librate from side to side, or in front, according to the attitude of the 
patient for the time being. 

A right or a left lateral obliquity is rendered very evident in a wo- 
man standing on her feet. In general, if the orean bears over to the 
risfht side, its faulty iirection will be corrected by turning upon the 
left, and vice versa. In anterior obliquity the fundus falls so far for- 
ward as to make the patient seem more lusty or larger than she really 
is, and the figure is greatly improved by wearing a suspensory band- 
age, which assists the rectus and obliqui abdominis to hold the 
gravid organ up nearer to the back bone. When a patient suffers her 
self to be annoyed by what she supposes to be an inordinate develop- 
ment of the womb, her fears may sometimes be allayed by showing 
he:, that n :: withstanding she is apparently enormously large, she is 
in reality not more lusty than common, and that the false appearance 
depends upon the anterior obliquity of the womb, which causes the 
belly to protrude unnaturally. 

Pressure of the Womb ox the Vessels. — Women, in whom the 
abdominal muscles have not lost their tone by repeated extensions 
in pregnancy, compress the uterus strongly, in a direction towards 



PREGNANCY. 205 

the back; whereas, those whose abdominal muscles have become 
weakened by repeated gestations, carry the child very low, to use 
a common term, allowing the enlarged womb to recline upon the 
muscles in front of it. In the former case, the pressure of the organ 
against the spine must, to a greater or less degree, interfere with 
the current of blood in the great vessels of the abdomen. Hence the 
aorta and iliac arteries, and some of their branches, will pass on 
their contents with less freedom than is natural, whereby the upper 
parts of the body become supplied with more than their due propor- 
tion of the arterial blood. Headache, vertigo, flushings of the face, 
and tendency to paralysis and convulsions, may fairly be attributed 
to the excessive momentum of the blood distributed to the superior 
parts, and determined towards them by this cause. Sighing, prae- 
cordial distress, dyspnoea and coughs are also found to depend upon 
the same principle, and are to be treated with a view to lessen this 
vicious distribution and accumulation of the vital fluids. Venesec- 
tion, looseness of the bowels, light diet, warm baths, and whatever 
tends to produce moderate relaxation of the muscular forces, are in 
general employed with signal success in these circumstances. 

Dr. Collins, App. 199, remarks, that " Puerperal convulsions occur 
almost invariably in strong plethoric young women with their first 
children, more especially in such as are of a coarse thick make, with 
short necks." He adds, at p. 201, "that of thirty cases occurring 
during his Mastership, twenty-nine were in women with their first chiU 
dren." 

Can this excess of propensity to eclampsia in primiparae be attri- 
buted to any other cause than the excessive sanguine determinations 
to the head above indicated ? I have been for some time impressed 
with the opinion, that women who lie on the back in labor, espe- 
cially in first labors, are more liable to convulsion on account of 
the greater pressure against the great vessels within the belly; a 
pressure which, at least, is always relaxed, during the absence of 
pain, in such as lie on the side. 

I have frequently met with coughs in the latter weeks of pregnancy, 
which proved rebellious against all treatment, until the delivery of 
the patient, after which they yielded to the common means of cure: 
the pressure of the womb on the abdominal vessels being removed, 
the pulmonary engorgement and irritation previously sustained and 
enforced thereby, proved no longer indomitable. 

The same pressure of the enlarged womb, above spoken of, inter- 
rupts the return of the blood from the extremities, and the transit of 



206 PREGNANCY. 

the contents of the lymphatic absorbents. Hence, when that pres- 
sure has reached its maximum, the feet and legs become cedematous 
or anasarcous ; the veins of the feet and legs acquire an enormous 
size, become permanently varicose, and in certain instances burst, 
so as to cause effusions of blood to take place. In like manner 
as has been stated of the superior or arterial engorgements, this 
inferior or venous engorgement ceases upon the abstraction of its 
cause. Limbs, when swelled even enormously, are observed to re- 
cover their natural size in three or four days after the accouchement. 
The same general plan of treatment is applicable to both the eases ; 
but it is particularly incumbent upon the medical attendant to em- 
ploy, in the latter case, rollers for the limbs, that may enable their 
vessels to overcome the distending causes. Where the oedema is 
very great and painful, punctures with a lancet, extending into the 
tela cellulosa, allow the serum to escape, and thereby are the means 
of procuring great relief, without the least danger, or any inconve- 
nience worthy of attention. In some cases the oedema of the limb 
is so great, that it extends, at length, even to the perineum, the labia 
and the lower part of the abdomen. I have mentioned instances in 
which each labium was swollen to four or five times its natural size, 
from this serous infiltration. In some of these cases the tumor has 
been hard and very resisting. It is proper to remark in this place, 
that women who are very much swelled in this way are to be deemed 
far more liable to puerperal convulsions than such as have no swell- 
ings ; for these infiltrations, produced by pressure on the ascending 
venous columns, suffer a similar pressure on the descending arterial 
columns of blood; which gives cephalic engorgement. Good care 
should be taken to obviate such dreadful attacks. To be forewarned 
is to be forearmed. 

That worthy old author, M. Puzos, whose Traite des Jlccouche- 
mens was published in 1755, gives, at page 84, a sensible account of 
the causation of this oedema gravidarum. "On scait que cette en- 
flure ne vient que de la difficulte que les liqueurs ont a remonter de 
bas en haut, et a. entrer dans le ventre ; parceque le poids de Pen- 
fant se fait bien plus sentir lorsque la femme est debout que couchee, 
et s'oppose plus fortement au retour de la lymphe, dans cette situa- 
tion, que lorsqu'elle est horizontale." 

Puzos, it is true, makes a just discrimination betwixt this accidence 
in Midwifery and a real dropsy ; but the Student will be misled, should 
he not be convinced that the vast majority of the cases of infiltration, 
no matter how extensive, are owing to pressure on veins and absorb- 



PREGNANCY. 207 

ents, and not to a true hydropic diathesis. This accidental dropsy 
from mechanical obstruction requires no treatment by drugs. Puzos' 
explanation as to position ought to be remembered, and a confident 
expectation should be indulged as to a cure, a spontaneous cure, as 
soon as the obstructing cause shall have been removed, by the birth of 
the child. 

A woman sometimes grows apparently very fat in the last weeks 
or days of her pregnancy — but, the appearance of embonpoint is false 
— the delusion arising from an insensible watery infiltration of the 
whole of the superficial cellular tela: instead of increasing her em- 
bonpoint she is really losing flesh by the constant waste of the watery 
part of her blood, and when she comes to her lying-in she complains, 
a few days afterwards, of growing thin, whereas she may be in reality 
growing fatter. The deception consists in the elimination of the wa- 
ter of infiltration, which lets her contour down to the true state and 
expression of her real embonpoint. 

Anemia Gravidi. — I have observed that this oedema gravidarum 
has in many women been attended with some maladive state of the 
organs or powers of the hsematosis. In my own opinion, the organ of 
the haematosisis the Endangium which I have elsewhere called the 
Blood-membrane. I am not surprised to find that the endangium 
becomes weakened or diseased in pregnant women, and especially in 
women whose blood-vessels are occupied in repairing the damage of 
the blood effected by such vast infiltrations as I have seen among my 
patients, in addition to the perpetual call upon them for the extraor- 
dinary supplies required for the gestation. Such a woman may get 
rid of the water of infiltration in three days, but she will be of an 
ansemical appearance for many weeks, and there is danger even of her 
becoming the subject of a real pathological and not merely accidental 
anaemia. 

The treatment of such persons consists, due alvine dejections be- 
ing premised, in the allowance of a nutritious diet, with a portion of 
wine, and the exhibition of the martial preparations; such as Vallet's 
mass, citrate of iron and quinine — or, what I deem preferable to either 
of them, the pill of Quevenne's metallic iron. 

Hydatid Degeneration of the Ovum. — A woman who has con- 
ceived in the womb, and in whom the pregnancy may have gone on 
for several weeks, or even for some months, in the most regular and 
orderly manner, is nevertheless liable to subsequent faulty progress in 



208 PREGNANCY. HYDATIDS. 

the development of the ovum. For example, the whole mass of the 
placenta may become the seat of an hydatid degeneration. Hydatids 
are transparent vesicles or bullae, colorless and distended with water 
resembling pure water. They are supposed by many authors to 
be independent animals, and were by Laennec denominated as the 
cysticercus. Mr. Milne Edwards, however, in his Elemens de Zoo- 
logie — Animaux sans Vertebres, speaks of them as belonging to the 
class of the Helminths or Entozoars. Under the order Cystoid 
Helminths, genus Hydatins, he says — "Finally, the Hydatids are 
generally considered as the last link in the series of intestinal worms ; 
but, the bodies described under this title are perhaps not real animals, 
and seem rather to be mere pathological products." 

M. Pouchet, also, in his Zoologie Classique, p. 537, torn, ii., says — 

" It sometimes happens that women, affected with all the symptoms 
of pregnancy, discharge a considerable quantity of delicate vesicles 
filled with an aqueous liquor, that are perfectly analogous to the cys- 
ticercus, and which have hitherto been regarded as hydatids. The 
vesicles seem to adhere by a pedicle to the organ that produces them. 
Bremser looks upon them as helminths, and says they are really en- 
dowed with individual life, and constitute a peculiar species of animals. 
But several French physicians do not partake of this opinion of the 
celebrated German helminthologist, and think that these pretended 
entozoars are commonly nothing more than a pathological degenera- 
tion of the product of conception. Such are the opinions of Messrs. 
Desormeaux, Velpeau, and Orfila, etc." 

I have translated the above passages from Milne Edwards, and 
Pouchet, in order to enforce the opinion I have to express as to the 
pathological and non-generical nature of the placental hydatid. I 
am inclined to regard them as depending upon an hydropic state of 
the villi of the chorion, which by a process of endosmose, under some 
maladive condition of the life-force of the ovum, is able to convert 
them into cysts, to the ruin of the product of the fecundation. 

When a villous chorion begins to be generally subject of this hyda- 
tid degeneration, it is to be deemed that the embryo must necessarily 
perish, in consequence of the destruction of its branchial organ, the 
placenta, which, after all, is nothing more than a cellulo-vascular pro- 
cess from the chorion. I have, however, seen some examples in which 
the placenta, at healthful term, has exhibited several of these hydatid- 
vesicles — and in others, the embryo has been discharged, accompanied 
with the debris of a placenta filled with innumerable small bullae 
resembling white grapes in bunches. 



PREGNANCY. HYDATIDS. 209 

Let the Student observe that the ovum, when invaded and con- 
quered by this attack, continues to augment in size, its progress being 
governed by no ascertained law of rate. The healthy ovum has an ex- 
act rate — it is finished in nine months — but the hydatid has no certain 
rate — it compels the womb to distend for its accommodation, and that 
at a rate which is uncertain. I have seen a young woman at the 
fourth month after conception, as large as she ought to have been at 
the sixth month. It is easy to infer that such a rapid deploying of 
the womb, one so different from the gentle and law r ful rate of a true 
pregnancy, must have the effects of a pathological, rather than those 
of a physiological force. 

The term to which the development of placental hydatids may at- 
tain in any special case can not be foreseen. The uterus may cease 
to tolerate their presence in the 3d, 4th, 5th, or even in the 7th month 
of gestation. 

The signs by which they are known are inferential or positive. We 
infer that the womb contains hydatids whenever we discover it to be 
increasing with preternatural rapidity; a rapidity that could not be 
predicated as to twins to polypus uteri or any tumor. We know that 
the case is one of hydatids whenever, upon Touching, we can find a 
softish mass in the cervix which bleeds upon being rudely pressed, and 
which discharges upon the finger or the napkins specimens of the 
aqueous vesicles. 

As soon as the diagnosis is made, one is ready to take advantage of 
the commencement of any dilating pain, to provoke the earliest pos- 
sible discharge of the hydatic mass. This may be done by introduc- 
ing the index finger into the os uteri far enough to reach and break 
up the mass. It mostly happens here, as it does in turning out coagula 
from the womb, after labors, that as soon as a portion, even a small 
one, is broken off and discharged, the uterus begins at once to con- 
tract upon its now lessened contents, so that, in general, the whole 
product rushes forth from the violently contracting organ. When, 
upon the discharge of a quantity of the hydatic mass, the labor-pain 
ceases, too soon it is well again to break in pieces the rest, so that, 
when the pain next comes on there may be less resistance to its expul- 
sion. The Touch reveals to us the truth at last, as to whether all the 
product is driven off or not. 

I have observed that, in the course of a labor for the expulsion of 
hydatids, the hemorrhage is occasionally most violent, and even alarm- 
ing. The tampon constitutes an unobjectionable means of arresting 
such a too troublesome waste of the blood. 
14 



210 PREGNANCY — FALSE. 

Intense constitutional irritation accompanies the hydatid pregnancy 
in those examples of it where the growth is violently rapid. The 
over-hasty development of the womb or matrix of the mass, may be 
compared to a bursting process. I leave it to the ingenious Student 
to study out the problem of the amount of constitutional disorder and 
its signs, likely to be made manifest upon such sudden and preterna- 
tural impetuosity of the uterine growth and deploy. 

Moles. — Moles are altered ova. In the case of a false pregnancy 
or Mola, as it is called, we are to presume the conception was normal, 
but that, upon some accidental failure of the development of the embryo 
or the secundines, the embryo perished and disappeared. In the mean- 
time, by the operation of a principle of vitality communicated through 
the uterus the mass continued to exist and to grow, until the w T omb, 
no longer tolerant of the foreign body, must commence a series of con- 
tractions, by force of which it is expelled. The mole, like the hy- 
datid, is called a false conception. Neither of them is a false concep- 
tion ; but a true conception changed afterwards by some accidental 
diseased action. 

Physometra. — There is said to be a false pregnancy called physo- 
metra or wind-pregnancy. I have recorded my opinion as adverse to 
this pretended state, in my Letters to the Class. I cannot conceive of 
a womb distended like a balloon with gas. Some of the Reviews with 
w T hich my Letters have been honored find fault with my recusancy as to 
Physometra and Hydrometra. I receive with the greatest respect, and 
even thankfully, the strictures that have appeared together with a cer- 
tain flattering amount of commendation of that work. Notwithstand- 
ing the remarks of my critics I feel constrained to maintain the opin- 
ions I there expressed, to which I beg leave to refer the Student. 

Hydrometra. — This is a state in which the womb becomes filled 
with water. The woman, supposing herself pregnant, suddenly finds 
herself deluged with water that, as is pretended, gushes in a torrent 
from the uterus, whereupon the signs of the pregnancy vanish away. 
Inasmuch as I cannot imagine the state of hydrometra, independent 
of some enormous sac, cell, vesicle or acephalocyst in which it is con- 
tained, and as the supposition of such vast cells is impossible, I ad- 
here to the opinion that Hydrometra is an hypothesis merely. I prefer 
to suppose the case to be one of over-distended bladder, and the water 
of the hydrometra to be urine. If the womb should become affected 



PREGNANCY. ABORTION. 211 

with atresia of the os tincae or cervix, and it should then fill with a 
great quantity of fluid, that fluid could not be water. I respectfully, 
therefore, claim to adhere to the dissenting opinions expressed in my 
Letters, to which again I refer the Student. 

Abortion. — The ovum, however well protected by its recondite 
situation against the operation of any extrinsic causes of destruction, 
is, nevertheless, obnoxious to several influences that may cause its 
miscarriage. There are also many intrinsic causes that tend to 
effect its death; for, since the foetus is composed of a structure, and 
has functions that are vastly complicated and mutually dependent, it 
must be liable to disorders that may interrupt its growth, or health, 
and at last cause it to be thrown off as an abortion. 

The embryo is so delicately organized, that very slight changes in 
the solids or fluids which compose it, are sufficient to determine its 
destruction. 

Its blood, out of which all its tissues are composed, is moved by its 
own powers of circulation, and it must, like all other living beings, 
be subject to engorgements, inflammations, hemorrhages, and all the 
other maladies that consist in derangements of the circulation. 

Such a creature might perish from very slight faults in the power 
of the omphalo-mesenteric vessels or the umbilical vessels — and un- 
equable development of its more important internal organs, doubtless 
serve, in many instances, to deprive it of vitality. Of the vast number 
of cases of early abortion, I presume a large majority depend upon 
disorders of the embryo itself, and not upon disorders or accidents 
happening to the mother. 

While this is probably true, it is to be observed that the union 
of the placenta to the surface of the womb is so slight, that it is 
easily peeled off; so that a blow upon the region of the womb may 
destroy its connection, and blood may become at once effused betwixt 
the placenta and the uterus: if a great quantity be effused, the whole 
surface of the placenta may be speedily detached or loosened, and 
of course, the ovum, now deprived of the sources of growth, must 
perish. 

A sudden and very violent excitement of the blood-vessels, as by 
surprise, anger, &c, may cause the effusion of blood from the pla- 
cental superficies of the womb. A contraction of the womb may 
break the connection. A violent concussion of the body, as by falls, 
jumping, or rude motion in carriages or on horseback, may cause a 
detachment to take place; or the membranes of the ovum may be so 



212 PREGNANCY. — ABORTION. 

weak and delicate, as to burst upon very slight compression of the 
womb, as in coughing, straining at stool — upon any sudden and 
powerful exertion, falls, blows, &e. Thus it appears that the abor- 
tion may be caused by the death of the embryo ; by disease of the 
secundines; by sudden violent movements of the blood, causing the 
effusion of that fluid behind the placenta; by direct violence, or by 
the discharge of the water of the amnion. 

If the ovum be ruptured, there is a discharge of water from the 
vagina, the quantity of which will depend upon the age of the em- 
bryo. This is sooner or later followed by pain, and^flowing of blood. 
The pains, which are uterine contractions, become more and more 
frequent and considerable, until the ovum or its remains are ex- 
pelled, when the bleeding begins to diminish, and for the most part, 
the pain returns no more. If any cause should have been applied 
that could detach a portion of the placenta without rupturing the ovum, 
many hours, or even several days might elapse, before the blood that 
follows the detachment should appear at the orifice of the vagina : the 
blood must first force its way betwixt the chorion, or decidua, and the 
surface of the womb; but as soon as it reaches the orifice, it falls into 
the vagina, and then there is what is called a show. If the foetus 
perishes by an internal disease, or in consequence of some disorder 
that happens to seize upon any part of the ovum, the further develop- 
ment of the ovum, or of the embryo ceases, and it is cast out by the 
contractions of the womb, sooner or later according to circumstances. 
For the most part, the ovum soon after it has lost its vitality becomes 
an irritant or excitant of the womb. On not a few occasions, how- 
ever, the dead ovum remains within the uterine cavity for weeks 
or even for months, without exciting its contractility — cases that 
are among the most embarrassing, on account of the diagnosis, that 
the obstetrician can possibly encounter. The dead ovum of three 
months may not be expelled until the seventh or eighth month of 
pregnancy. It undergoes no putrefaction, unless the membranes have 
been ruptured ; in which case it cannot remain very long undischarged. 

There are some individuals in whom there seems to be so great an 
irritability of the muscular fibres of the womb, that the presence of 
the fruit of a conception never fails to bring on the contractions be- 
fore the completion of the term of pregnancy; and I apprehend that 
this excessive irritability is among the common causes that produce 
abortions. This view seems to be maintained by a reference to what 
happens in those who have already miscarried, since such females 
are found to be greatly disposed to miscarry again, at about the same 



PREGNANCY. ABORTION. 213 

period as that at which they had sustained the first misfortune ; which 
appears to me to indicate, that the repeated accidents of this kind are 
attributable, rather to an excessive or abnormal irritability of the womb, 
than to any of the other circumstances that are enumerated as causa- 
tive of abortions; for it is far more reasonable to suppose that the 
same uterus is endowed with too great a degree of muscular irritability, 
than to suppose that several successive germs should be so consti- 
tuted as to perish always at about the same period. 

A woman becomes pregnant by the fecundation and fixation 
of a deposited ovulum. The act of fecundation can only take place 
after the ovi-posit has happened. The conception does not 
necessarily put a stop to the periodical development 
of ovarian ova — nor to their maturation and fall. But a 
woman who menstruates because of her ovi-posit, will tend to men- 
struate at regular periods, though she have conceived in the w T omb. 
Some women have this tendency so strongly, that they do actually 
menstruate during the earlier months of their gestation. Mrs. K. 
menstruated until the eighth month of her pregnancy. 

The above may serve as an explanation of the very common opin- 
ion that a woman is most liable to abortion at periods coinciding with 
the menstrual effort, and there is good reason to believe that a great 
number of abortions do take place at those conjunctures. It is reason- 
able to suppose that the periodical hypersemia of the reproductive 
organs that causes menstruation w 7 ould, should it occur in pregnancy, 
expose the woman to the risk of miscarriage — and it is equally rea- 
sonable to take especial precautions against such an occurrence for 
those women who have, on former occasions, suffered the loss of the 
ovum, at or near to the menstrual periods, and without any other 
assignable causes. 

Whenever in abortion, the contents of the gravid womb come to 
be expelled from its cavity, that expulsion is effected by a real labor, 
often most severely painful, and requiring for its completion many 
hours of greater or less suffering. 

I have had the medical charge of the same women in regular labor 
and in abortion; and they have informed me that, for acuteness and 
severity of pain, the abortion has far exceeded the labor at term. 
This is not always, nor, perhaps, most generally the case. The rea- 
son why women suffer so acutely in miscarriages is, that the canal of 
the cervix uteri requires for its dilatation, in the early months, a great 
deal of power to be employed in forcing the embryo, which at that 
time is contained in the cavity of the body and fundus, down through 



214 PREGNANCY. ABORTION. 

the long narrow canal of the cervix uteri ; and the distress produced 
by this dilatation of a long and rigid canal must often be as great, 
and might, a priori, be supposed as great as that occasioned by the 
dilatation of the os uteri at term, which in the last days of pregnancy 
has become thin and yielding ; whereas, in the early months, the 
whole cervix, as well as the os uteri, is of an almost cartilaginous 
hardness and rigidity. 

Abortions sometimes take place very easily, with little pain, and 
almost without hemorrhage ; but, the quantity of blood lost in some 
instances of miscarriage is enormous ; probably on account of the ex- 
treme degree of uterine irritation or sanguine molimen which the act 
of abortion develops. The hemorrhage is apt to continue until the 
contents of the womb are expelled; and it is, therefore, highly import- 
ant to expedite that occurrence by all reasonable means. Unfortunately 
these means are few. 

Upon taking charge of a case of abortion it is the Student's duty to 
ascertain which of two indications he ought to pursue. First, he 
should decide whether he will attempt to save the pregnancy, by pre- 
serving the vitality of the ovum ; and second, he should determine whe- 
ther any moral probability now exists of the death of the ovum. In the 
latter case it demands his respect no longer; in the former he will act 
against duty if he fails to do whatever may hopefully tend to the con- 
servation of the fruit of the womb. The quantity of blood lost already 
may serve in some degree to enable him to decide both these ques- 
tions; for if the pregnancy be not much advanced, the loss of a con- 
siderable quantity of blood is evidence of so incurable a detachment 
of the fixed ovum as to preclude any reasonable expectation of its 
continuing to live in the womb. 

Besides his inquiries and observation as to the quantity and force 
of the hemorrhage, he should carefully ascertain by Touching the ex- 
isting condition of the os and cervix uteri. Therefore, whenever the 
flow becomes so considerable as to affect the pulse and the complexion 
of the patient, it is imperatively required that the medical man should 
ask for an examination per vaginam ; and he will sometimes find that 
the ovum is sticking in the cervix, and needs only a little aid to escape 
from it — but, while it remains, it cannot but keep up the hemorrhage. 
The fore finger may, in such instances, be pushed as far as practica- 
ble within the canal of the cervix, along side of the ovum, and then 
bent so as to resemble a blunt crotchet. By the aid of the finger, 
used in this way, and the assistance of powerful bearing down on the 
part of the woman, the offending cause is without much difficulty re- 



PREGNANCY. ABORTION. 215 

moved, and the effect ceases. When the finger cannot be employed, 
Dr. Dewees' placenta-hook answers extremely well in some examples, 
as I have had occasion to experience. 

I annex a figure (Fig/68) of Dr. Dewees' placenta hook or crotchet, 
which is on some occasions a convenient instrument for pulling down 
the ovum when merely held by the cylindrical grasp of the cervix. 

Fig. 68. 



=2> 



Dr. Henry Bond, an eminent practitioner of this city, has proposed 
a placenta forceps for the delivery of the secundines in abortion, of 
which Fig. 69 is a representation. 



Fig. 69. 




Dr. Bond's instrument is ten inches in length, and so rounded that 
it is difficult to conceive of an operator awkward enough to pinch with 
it any of the parts of the mother. An inspection of the drawing suf- 
fices, without further explanation, to give an idea of its usefulness. 

While I lay before the Student these instruments for the extraction 
of the dead ovum, I ought to warn him against too facile a disposition 
as to the employment of them, and to assure him they will often disap- 
point his expectations, and sometimes where they do succeed, lead to 
evil consequences as to the mother. The ovum, in abortions, inhabits 
the body and fundus uteri. The cervix stands guardian as the facultas 
retentrix over the deposite, and reluctlantly yields it a passage. In 
doing so the conical neck of the womb must become a cylindrical 
canal, into which the fundus and corpus uteri thrust their intolerable 
burden. When this cylindrical canal hath received into its calibre a 
small ovum, or the remains of one, it has, of itself, little or no power 
of expulsion, but merely grasps the ovum and holds it fast. It holds 
it sometimes for many days. I have found it to hold the ovum in this 
manner for many consecutive days, because the very os uteri would 
not let it escape, refusing to yield, chiefly perhaps because no dilating 
pressure was applied. In the long run it yields, the os tincse becomes 
wide open, and then, a bearing down effort, a fit of coughing — or 



216 PREGNANCY. — ABORTION. — TAMPON. 

straining at stool or urine drives it forth into the vagina. Now, until 
the canal has become truly cylindrical, Dr. Bond's forceps and Dr. 
Dewees' hook are not to be employed without much care and gentle- 
ness. For the most part it is better to wait until all is prepared and 
then remove the object with the index finger. 

In those cases in which a proper attempt to extract the debris of the 
ovum has failed, those who like the support of high authority may 
console themselves by referring to Puzos, who at page 193 says that 
" eette terminaison est bien moins effrayante; mais elle est bien plus 
longue; jai vu de ces fontes durer six semaines a deux mois; et 
pendant tout le temps, ou les vuidanges sont si foetides, jai vu ces 
fernmes tourmentees de fievres irregulieres de degouts et d'inquiet- 
udes." He thinks these cases ought to be left to nature. 

If, upon making examination in abortions, the state of the cervix is 
found to be unfavorable to the speedy expulsion of the offending cause, 
and the hemorrhage be not too threatening, recourse may be had to the 
application of napkins, wrung out of cold vinegar and water, to the 
hypogastrium and pudenda; to the administration of dilute aromatic 
sulphuric acid ; to the acetate of lead, with opium ; or to the preparations 
of secale cornutum — as the powder, in doses of five to ten grains re- 
peated pro re nata, or its vinous tincture, of which a teaspoonful may 
be given every half hour, or at intervals of one or more hours, accord- 
ingly as the events of the case seem to demand. A powder consisting 
of five grains of alum and one grain of nutmeg may be given as a 
hemostatic every half hour or hour. The lancet may be resorted to, 
to aid, both in diminishing the hemorrhagic nisus, and in favoring the 
dilatation of the cervix, to which nothing contributes more powerfully 
than venesection. This, however, should be used with great good 



Tampon. — But above all the means of nutting an end to troublesome 
hemorrhage, I ought to applaud the tampon, or plug. This tampon may 
be composed of a sponge; or, what is far better, of pieces of cotton or 
linen cloth or patent lint, torn into squares of from two to three inches, 
which may be pressed into the vagina, one at a time, until that entire 
canal is filled and distended with them. They should be kept there 
by a napkin, worn as for the menstrua, or by pressure with the hand 
of a nurse, a napkin being interposed, until the flow is effectually 
checked, at least. The tampon may be allowed to remain in situ from 
six to twelve, or even to twenty-four hours in winter; and when re- 
moved, it is generally followed by the ovum, or its remains, which 



PREGNANCY. ABORTION. — TAMPON. 217 

are frequently found attached by a coagulum to the upper part of the 
tampon. Should any dysury be caused by its presence, the bladder 
may be readily relieved by the catheter while the woman preserves a 
horizontal posture, which should never give place to a vertical one, 
until all probability of a return of the hemorrhage has disappeared. 

I do not understand how a woman can be permitted to die with 
hemorrhage, in an abortion, while materials for a tampon are at hand, 
since the discharge may always be effectually controlled by it. The 
remedy gives no pain, if properly used; and, so far as my experience 
of its employment bears me out, it never causes any considerable in- 
convenience; while, I may add, it always succeeds. 

A good many cases of abortion, in the early stage, as from the sixth 
week to the tenth week, have fallen under my notice, in which the 
uterus was unable to expel the remains of the ovum, and in which I 
could not extract it. The female, in such instances, save one, has 
always recovered without the ovum having been visibly discharged ; 
but there always was an excretion, continued for many days, of offen- 
sive dark-colored grumes and sanies, which I accounted for by sup- 
posing that the substances in the uterus had macerated and come off 
in a state of semi-solution, as in the instances above cited from 
Puzos. I think that there is no danger in leaving such occurrences 
in the hands of nature ; and that it is better to do so than reiterate 
attempts to extract by force, that have perhaps already proved quite 
vain ; especially, considering that there is as great danger of exciting 
inflammation by those attempts, as could be anticipated from the gra- 
dual maceration of the ovum. I am not disposed to deny that the 
presence of a putrefying substance, even of a small size, in the 
womb, is capable of developing violent inflammation and fever; but 
it has not happened so with me, and I have given the same opinion 
to some medical friends, by whom I have been consulted, without the 
least cause to regret having given such advice. Let me be clearly 
understood, however, to recommend that the last remainders of the 
ovum should be brought off, where it is practicable by means of any 
reasonable efforts to do so. 

I shall not omit the present opportunity for repeating, w T ith regard to 
the tampon, that it is not a proper remedy for those cases in which 
any hope is yet entertained of saving the pregnancy. 

Let us suppose an instance in which the placental attachment has 
taken place at the fundus uteri; that a partial detachment of the pla- 
centa has happened, and that the blood, having forced its way in a 
narrow stream, or rivulet, betwixt the womb and the outer surface 



218 PREGNANCY. — ABORTION. TAMPON. 

of the ovum, has at length made its appearance at the pudendum. 
Nothing is more common than to see such cases of show suppressed 
by venesection, recumbency, an opiate, some doses of elixir of vitriol, 
or cold lemonade. Should any practitioner, anxious to promote the 
formation of a coagulum, and thereby stop the effusion of blood and 
save the pregnancy, have instant recourse to the tampon, what would 
be the consequence? The blood, instead of escaping externally, 
would be forced back on the ovum, while the newly effused portions 
of it, instead of flowing by the route already formed, would continue 
to dissect off or separate the ovum more and more, until the whole of 
it should be detached, and at last come off, enveloped in the centre of 
a compressed clot. To use the tampon, therefore, is to ensure the 
abortion ; hence it is only a remedy for the hemorrhage of abortion, 
and not a remedy for miscarriage, which it not only cannot prevent, 
but actually ensures, or renders certain. The blood which continues 
to flow into the womb, after the vagina has been closed by the tam- 
pon, may be compared to a river dammed across its channel, and 
whose waters, in consequence, overflow their banks, drowning the 
adjacent country. 

With regard to the tampon, I have further to add, that its employ- 
ment in advanced stages of pregnancy, although allowable in certain 
instances, demands very great discrimination, inasmuch as it is capa- 
ble of converting an open into a concealed hemorrhage, as we shall 
have occasion more fully to remark when we come to the considera- 
tion of uterine hemorrhage, in labor. It may, under the proper indica- 
tions, be with safety employed up to the close of the fifth month of 
gestation ; since the womb, until that period, is incapable of admitting 
sufficient quantity of blood to give any well grounded fears of a fatal 
concealed hemorrhage. But at a later stage, the capacity of the ute- 
rus is so much increased that the tampon, if employed at all, ought 
only to be used while the practitioner himself carefully observes its 
effects, remaining at hand to remove it in case the uterine cavity 
should become distended and filled either with fluid or coagulated 
blood to a threatening amount. I was told, not long since, of an 
instance in which a gentleman, treating a case of hemorrhage, after 
delivery, was pressingly called for to visit another woman in labor, 
and as he felt compelled to go, he tamponed the vagina with his hand- 
kerchief, by which means he effectually suppressed the apparent he- 
morrhage, but, upon returning shortly afterwards, he found the patient 
dead ; the womb having filled with blood, instead of that fluid having 
escaped at the vulva — just such a conclusion to the affair as ought to 



PREGNANCY. PROLAPSUS. 219 

have been expected from the use of the tampon under such circum- 
stances. 

It has on several occasions happened to me to see the tampon inju- 
diciously employed in this way. Two of the persons were nearly ex- 
piring when I arrived and immediately removed them, and one other 
for whom it had been applied early in a flooding labor, without pla- 
cental inplantation, was expiring when I reached the house — a dread- 
ful case of mala praxis to which I shall recur in a future page. 

Prolapsus. — It is commonly thought that women who suffer under 
repeated abortions, are quite as much if not more subject to a conse- 
quent prolapsus uteri than those who are confined at full term. The 
natural tendency of labor is to produce a prolapsion of the womb, and 
that tendency must be much greater where the vagina has been much 
distended and pressed out of its ordinary form, than where the vagina 
has not been so affected. This might lead one to deny that abortions 
are as likely to bring on a state of prolapsus as labors at term. But 
those women who miscarry are, for the most part, not sick any longer 
than during the actual miscarriage. They generally get up, most 
imprudently, the next day, or in some instances even on the same day. 
The solid and weighty substance of the uterus now bears down the 
vagina, to whose upper extremity the organ is attached ; and the 
vagina, weakened and relaxed by the discharges of the miscarriage, 
and ofttimes after abortion, affected with vaginitis, makes less resist- 
ance than is common, so that tire womb takes permanently a much 
lower level in the pelvis than it ought to have. All the difficulties and 
embarrassments likely to accrue from this vicious situation of the womb, 
might be obviated by a little patience and prudence in the beginning. 
The woman should be warned in clear intelligible language that too 
early a getting up exposes her to the risk of suffering from a falling or 
bearing down of the womb, which may ruin her health and thereby 
render her unhappy for life. Unfortunately, she feels too well to believe 
that our words are other than useless and needless vaticinations, and 
so she is not willing to maintain a recumbent posture more than one 
or two days. 

It should be considered that while a woman, lying-in, is in a physi- 
ological state, one laboring under miscarriage is in an opposite con- 
dition — that she is sick, and often needs care not less sedulous than 
the other one requires. The womb is in fault, as to the miscarriage 
in some of the cases, and any man conversant with the events of our 
obstetric practice knows that the organ is occasionally left inflamed, or 



220 PREGNANCY. RETROVERSION. 

hyperaemic, and irritable to the last degree. In these instances the 
organ is situated much as it is when affected with hypertrophy. Long 
continued uterine tenesmus, sanguine affluxion, enfeebling discharges 
and persistent pain, might well be expected to result in a descent or 
prolapsus, scarcely to be avoided by those who suffer frequent distress- 
ing abortions, and especially by those who pay not the least regard to 
the common sense dictates of the medical man. 

Retroversion. — In proportion as pregnancy advances, the womb 
increases in longitudinal diameter; so that if it should from any cause 
happen to be turned over backwards, the top of the fundus uteri would 
lodge in the hollow of the sacrum, while the os tinea? would be pressed 
upon the symphysis of the pubes, or above it. The fact of such a dis- 
placement being occasionally met with cannot be doubted, and the 
inconveniences and dangers arising from it are too numerous to admit 
of my passing over it here without a few remarks. 

Considering that the antero-posterior diameter of the pelvic exca- 
vation is equal to four and a half inches, it is reasonable to suppose 
that the unimpregnated womb cannot readily be caught under the 
projection of the sacrum, even if it be liable to be thrown backwards 
under that promontory. Yet the unimpregnated uterus is liable to be 
turned over, or retroverted, and retained in that false position, until 
the reposition of it be effected by a skilful hand. The womb is about 
three inches long; but as the vagina is attached by the recto-vaginal 
septum to the gut behind, it appears that if the fundus uteri should 
be caught, in retroversion, below the promontory of the sacrum, it 
might readily remain there, until, as above said, it should be reposited 
by the hand of the attendant. There is no reason to doubt that the 
uterus is frequently turned over backwards, but not retained; for the 
urinary bladder, when very full of water, extends backwards and 
downwards, pushing the top of the womb along with it. If this hap- 
pen to a woman about two and a half or three months gone with 
child, she will scarcely fail to have a serious retroversio uteri. 

There are persons who bring on these uterine deviations by a bad 
habit of retaining the urine until the bladder becomes over-full. Such, 
at least, is the opinion I have formed from inquiries addressed to the 
patients themselves. 

Some women, from a fastidious delicacy, or from circumstances of 
the society in which they pass their hours, fail to yield to the ordinary 
solicitations of nature as to the discharge of the urinary bladder, and 
allow that organ to become so distended that it equals the bulk of a 



PREGNANCY. — RETROVERSION. 221 

pint or even a quart measure, before they take notice of it. So great 
a bulk as this occupying the space behind the lower portions of the 
abdominal muscles and betwixt them and the sacrum, cannot but put 
upon the stretch both of the ligamenta rotunda, wdiich is equivalent 
to the effect of thrusting the fundus uteri down upon, and even below 
the promontory of the sacrum. 

Can there be any doubt that such a habit, persisted in for years, 
would result in the state of retroversio uteri ? 

I saw this day, July 12, 1848, a young lady of 22 years of age, 
who has been married now ten months. She presented all the exter- 
nal characteristics of fine health. She has never conceived. She has 
a constant pelvic distress, and has suffered for eight years with the 
most distressing dysmenorrhcea, informing me that she has never had 
her catamenia without very violent pain. The menstrua are abundant 
and regular. She uses a dozen napkins at each period, and some- 
times more than a dozen. There is severe pain in coitu, which can- 
not be perfectly effected. 

I found the os tincse half an inch behind and below the crown of the 
pubal arch — and the fundus uteri occupied the recto-vaginal cul-de- 
sac. 

Upon causing her to turn over upon the face I readily reposited the 
womb — but it came down again upon the least motion. Now this 
person had never had any considerable illness nor met with any acci- 
dent. When I pressed the index finger firmly on the lips of the os 
tineas or on the cervix she felt acute pain, and said the pain was the 
same in kind as that of her dysmenorrhcea. Her habit has always 
been to retain the urine long, so that sixteen or twenty ounces fre- 
quently collect before she discharges it. Can there be any doubt this 
habit is the cause of the retroversion? There is no other discovera- 
ble cause. 

Suppose the fundus of a gravid uterus to be caught and detained 
under the promontory, as just above mentioned, and that the child 
proceed in its growth, carrying with it the w T omb in wdiieh it is en- 
closed; the consequences must be a complete impaction of the womb 
into the excavation — a total prevention of the flow of urine, by pres- 
sure on the urethra — a stoppage of the canal of the rectum — severe 
pressure upon the internal sacral foramina, with their nerves ; and un- 
less by timely measures obviated, the certain and miserable death of 
the patient. In the case examined by Dr. Hunter, so completely im- 
pacted, or jammed w T as the womb into the cavity of the pelvis, that 
after the death of the patient it was found impracticable to get the 



222 PREGNANCY. RETROVERSION. 

uterus up out of the excavation, until the pubis was cut through with 
a saw, in order to admit of the enlargement of the brim of the pelvis. 
It is difficult to conceive of a situation more frightful than that of a 
patient under such circumstances. The case, with the fine illustra- 
tive engraving, is contained in Hunter's Tables of the gravid womb. 

As to the retroversions that follow pregnancy, I conceive that they 
are the after-labor results of non-contracting ligamenta rotunda. 
When the womb has attained its full size, at term, the round liga- 
ments have become much elongated, rising high up in the abdomen 
to their points of origin near those of the Fallopian tubes. If now the 
uterus, in a labor of some four hours, condenses itself, and in some 
fifteen days afterwards nearly recovers its non-gravid volume and 
weight, it does not necessarily happen that the round ligaments shall 
be equally active in their own reduction to their usual state. But, if 
they continue flaccid, relaxed, and elongated, nothing is left to hold 
the womb in proper propinquity to the symphysis pubis — it falls over 
against the promontory, is pushed beneath it by the distending blad- 
der, and held in such dislocation by the mechanical form of the curve 
and the promontorium. 

My experience teaches me that most of the instances of retroversion 
are attributable to a distended bladder, whether after parturition or 
no. The modest delicacy of women often compels them to resist 
the most urgent desire to pass off the urine. A female riding in a 
carriage, or placed in such a situation that she cannot withdraw 
from the company without being suspected of a desire to rains 
will allow the bladder to fill almost to bursting; and if she be preg- 
nant about three months, she will scarcely fail to have retroversion 
of the womb. When at last she obtains an opportunity to evacuate 
the bladder, she finds she has a partial or total suppression of urine. 
The usual recourse is had to spirits of nitre, to water-melon seed or 
parsley root tea, and, perhaps, a dose of castor oil may be resorted to; 
but as relief can only come by some mechanical remedy, the medical 
man is at length, and reluctantly, sent for. 

Case. — A few years ago I was called to a young woman who had 
been a short time married. She arrived in town by one of the pub- 
lic conveyances from the eastward. She had a constant and irrepress- 
ible desire to urinate, and could only succeed in getting off a few 
drops at a time. She told me she was pregnant; had just arrived 
from a journey, and that she was suffering the most acute distress 
from irrepressible inclination to urinate. As the disorder had come 



PREGNANCY. RETROVERSION. 223 

on suddenly and in a state of high health, I at once told her she 
had a retroversion, the nature of which I explained to her, and she 
submitted to the necessary investigation ; upon which I found her 
womb turned over, and upon repositing it she was immediately cured. 
I suppose that, in traveling, her bladder, for want of an opportunity 
to empty it, had become very much distended; that its bas-fond had 
pressed upon the anterior superior face of the womb more and more 
as it became more and more distended, until the fundus uteri, jammed 
under the promontory of the sacrum, could not get out again, without 
the aid of a physician. — Vide my Letters to the Class, sub voce. One 
of my critics condemns the rapdity of my diagnosis in the case. I 
respectfully refer him to the passages in which I explained, that by 
using the method of exclusion in the analysis, I could not possibly 
arrive at any other opinion. 

To see a healthy-looking woman seized with complete retention 
of urine, without having been before the subject of any urinary ail- 
ment, is always warrant enough for us to suspect a retroversion of the 
womb, especially if the patient be at the time pregnant, and not ad- 
vanced beyond the fourth month. The symptoms of which such 
patients complain are either a total retention, a stillicidium, or a 
great dysury; with pains about the region of the pubis and sacrum, 
constant tenesmus, or bearing down, and a sense of obstruction or 
stoppage in the rectum. 

No case like this ought to be suffered to pass without making an 
examination pervaginam. For this purpose let the patient lie on her 
back, near the right side of the bed; the feet drawn up near to the 
breech ; the head and shoulders raised with pillows. The physician 
should stand by the bed-side, and with his left hand placed upon the 
hypogastrium, ascertain if the bladder be much distended: it will 
sometimes be felt almost as high up as the umbilicus. The fore finger 
of the right hand may next be carried into the vagina, in order to 
seek for the os tincse, which is to be found behind the symphysis 
pubis, or even thrust over and above it: the vagina seems to be ob- 
structed by a hard body, which is the bas-fond of the womb, whose 
fundus is turned down into the hollow of the sacrum, and jammed 
into the cul-de-sac, composed of the reflexion of the peritoneum, 
which lines the upper posterior half of the vagina and the front of the 
rectum. 

Having thus verified the existence of a retroversion, the next steps 
required to be taken are those that are demanded for the repositing 
the womb. Among the most pressing indications of cure, is the re- 



224 PREGNANCY. RETROVERSION. 

lief of the suppression of urine, which in general is easily fulfilled 
by the introduction of the catheter, which should be a male catheter, 
composed of the French elastic material. A long one is the best, 
because the womb, in changing its own position, carries up the neck 
of the bladder, and thus elongates the urethra so very considerably, 
that it will be found convenient to use a long instrument for the eva- 
cuation of the water. 

Inasmuch as the most ordinary cause of retroversions is a distended 
bladder, it has been thought that the removal of this distension is the 
sufficient remedy, it being supposed that the uterus might recover its 
attitude as soon as the pressure which overset it should be taken off. 
Indeed, there are cases in which the restoration takes place soon after 
the bladder becomes emptied. I have related in my " Letters on 
Females, &c," cases of retroversion cured by the catheter alone, and 
one, from an English authority, in which a most dangerous case of 
retroversion in pregnancy, which could not be cured by the hand, 
gave way to the use of the catheter, left for a longtime in the bladder, 
by which means that organ was completely hindered from filling up, 
and obstructing the efforts of the fundus to rise upwards to its natural 
situation. It has well been contended that for retroversion of the 
gravid womb, a sound discretion indicates the propriety of leaving the 
case in nature's care, after this preliminary measure has been accom- 
plished, lest by any rude or too persevering attempts to replace the 
uterus, the ovum might suffer so much injury as to bring on an abor- 
tion. I admit that I am not prepared to decide as to the necessity for 
such great prudence, since I have only on one occasion put it to the 
test. On that occasion I drew off the urine two successive days, 
the accumulation being very great; and then finding that the mal-po- 
sition was not rectified, I was compelled to replace the womb with my 
hand: no inconvenience whatever followed the operation, although 
the patient was near four months complete, gone with child. In a 
subsequent pregnancy, the same person suffered a retroversion of the 
womb, nearly at the same period ; and when I was called to see her, 
I immediately proceeded to restore it to the proper attitude. In this 
case also the pregnancy was not in the least interrupted. 

Having succeeded in drawing off the water, the patient, if neces- 
sary, should have a copious enema, in order to unload the rectum, 
which, if replete with faecal matters, might offer considerable obsta- 
cles to the success of our attempt. In the next place we ought to 
endeavor to raise the fundus, the patient lying on her left side, by 
pressing the bas-fond of the w T omb, which can be felt through the 



PREGNANCY. RETROVERSION. 225 

hinder surface of the vagina, upwards, with the fingers, so as to lift 
the whole mass in a direction parallel with the axis of the brim. 
The cervix uteri is tied to the more anterior parts of the pelvis by 
the vagina and the vesico-vaginal septum, so that if we carry the 
mass considerably upwards, it must be by tilting the fundus in that 
direction. Attempts of this kind will not always succeed. Where they 
fail, a finger may be passed into the rectum, the fore finger of the left 
hand, if the woman is on her left side, and of the right hand if she be 
upon her back. Before the finger has passed very far, it meets with 
the fundus uteri, which presses upon the canal of the intestine ; in this 
situation we have far more power to move the womb than when the 
effort is made only from the vagina. Pushing gently and steadily 
upwards, we find the mass gradually to recede, until at length the fun- 
dus, liberated from its restraint, suddenly emerges, with a sort of jerk, 
from under the promontory, from which instant the woman is cured. 

I have sometimes failed of success, until I placed the patient in a 
more favorable attitude; one in which she could not bear down, and 
thus oppose the success of my measures. I have directed that she 
should turn on her face ; then draw her knees up under her until the 
thighs were in a vertical position, giving to the pelvis the highest pos- 
sible elevation: the face was to be placed on the bed without pillows, 
and the point of the thorax was also to be touching the bed. Lying 
in this posture, the power of mere gravitation might suffice, in time, to 
unhitch the fundus uteri from beneath the promontory ; since all tenes- 
mus and bearing down are thus arrested. After waiting a short space, 
until the effects of the position were secured, I have pushed up the 
fundus very easily by acting either through the vagina or the rectum. 

A woman who has just recovered from a retroversion, ought to lie in 
bed two or three days, and should not, for a few days, be left more 
than six or eight hours without evacuating the bladder, spontaneously 
or by the catheter, lest that organ, filling again, should unhappily a 
second time depress the fundus, and thus cause us to lose all our 
trouble for want of a moderate precaution. 

The gravid womb, doubtless, becomes, in four months and a half, 
too large to admit of the occurrence of retroversion : but the accident 
may occur at any period short of it ; it may take place not only in the 
non-gravid, but in the virgin uterus. 

Case. — On the 22d of February, 1828, 1 was called to visit Elizabeth 
B., aged about twenty years. She had complained for several months 
past of dragging pain in the left side of the abdomen, with a sense of 
15 



226 PREGNANCY. — RETROVERSION. 

weight and great uneasiness within the pelvis. She has menstruated 
regularly. For the last three weeks she has been persecuted with con- 
stantly repeated and painful desire to go on the stool; with symptoms 
of strangury, or dysury, amounting often to stillicidium urinae. After a 
careful inquiry into the history of her case, I informed her of the nature 
of my diagnosis ; and she at length agreed to permit an examination 
by the Touch, as I assured her that I had no means of relief for her, if 
there were really a retroversion, short of the Touch. In this painful 
necessity she submitted, with a laudable unwillingness, to the opera- 
tion, and it was with no little difficulty that I at length carried the 
finger beyond a remarkably strong hymen into the vagina. The os 
uteri was found near the symphysis of the pubis, and the fundus was 
discovered overturned into the peritoneal cul-de-sac. After a long 
perseverance in endeavoring to raise the fundus, I was compelled to 
attempt it with the forefinger of the left hand passed into the rectum, 
by which method I pushed the uterus up ; whereupon she immediately 
declared that she was fully relieved of the sense of weight and pain 
that had so long been tormenting her. She continued well from that 
moment. I consider this a case of considerable interest, inasmuch as 
it further proves the possibility of a long-continued retroversion of the 
womb in the non-gravid and virgin state of that organ. 

There are some persons to be met with, in whom retroversion takes 
place so readily, that the least exertion of strength brings it on. Tn 
a single individual I am sure that I have been called on to restore it 
to its position twelve or fifteen different times. So great, in that case, 
is the tendency of the womb to turn over, that it has several times 
occurred, notwithstanding the presence in the vagina of a very large 
globe pessary, and I do never regard her as exempt from the proba- 
bility of an attack except when in a state of pregnancy. I presume 
that in her case there is not only a great relaxation of the vagina and 
its connecting media, the recto and vesico-vaginal septa, but there 
must also be supposed to exist a condition of the ligamenta rotunda, 
which has allowed them to become elongated to such an extent that 
the least pressure on the anterior face of the womb pushes it back- 
wards and downwards. No one, I think, could suppose a case of 
retroversion, without at the same time implying the round ligaments, 
which pass from the angles of the organ out of the abdominal canal, 
and abdominal rings, to be lengthened — and even stretched. A per- 
manent elongation or laxity of those ligaments would add a great 
facility to the disposition to oversetting of the organ. 

As there is reason to believe that there is a character of muscu- 



PREGNANCY. RETROVERSION. 227 

larity attached to the round ligaments, proceeding as they do from, 
and being composed of, the same tissues as the womb, we may indulge, 
in any case, the hope, that time, if not drugs and medicines, will 
bring them back to their natural tension and length, so as to obviate 
the evil propensity to the retroverted state of the uterus. 

The accident of retroversion may be considered serious or danger- 
ous just in proportion as it occurs at a more advanced period of preg- 
nancy ; for, according as the pregnancy is of an older date, is the 
necessity greater for a speedy reposition of the organ. I have, I think, 
pointed out sufficiently at length, the dangers to be apprehended from 
a retroversion continued until the whole mass becomes so impacted 
into the excavation, as to render its extrication, without abortion, im- 
possible. As I have met, hitherto, with no example in which it was 
impossible to replace the gravid organ, I do not feel it incumbent upon 
me, at this time, to do more than refer to the severer methods of extri- 
cating the woman : which are, first, the artificial rupture of the amni- 
otic sac, which, by allowing the water to escape, reduces the size of 
the womb so much as to enable the operator to succeed in restoring 
it to its proper position; or lastly, the puncture of the womb itself, 
when it is found impossible to pass a bougie into the os uteri. 

The Student ought early to become aware that some of these retro- 
versions are rendered incurable by the formation of adhesive deposits 
that tie the fundus uteri close down to the back part of the pelvis; 
and that as these adhesive bands cannot be approached with the bis- 
toury nor otherwise broken up, the womb is liable to remain in a state 
of permanent retroversion. M. Amussat mentions two such cases in 
his Essay on retroversion, and I have met with two, one of which 
only was verified by the necroscopy. I shall publish one case as 
drawn up by Dr. Yardley, and illustrate it by a cut copied from a 
drawing by Mr. Mcllvaine, who had the specimen before him; and 
which constitutes one of the most interesting preparations in the Mu- 
seum of the College. The following is the history of the case, as 
drawn up by Dr. Yardley himself, who allows me to publish it here. 

Case. — "Mrs. N became my patient in the spring of 1840. 

I visited her on account of a diarrhoea which had continued for some 
time, and which was attended with distressing pain in the left side. 

"A regulated diet, saline frictions of the skin, which was cold 
and dry, together with small doses of mass, hydrargyri, opium, and 
ipecacuanha, soon cured the diarrhoea; but, as the pain in the side 
and other symptoms of disease still continued, I was induced to 



228 PREGNANCY (TUBAL). — ■RETROVERSION. 

investigate the case more fully. I then learned that since her mar- 
riage, about three years previously, she had had two attacks of 
uterine hemorrhage, which were pronounced by her physician to be 
abortions ; though nothing like an ovum had ever been detected, and 
he had never examined the state of the uterus. 

"The first attack came on on New Year's day, 1838, after taking a 
very long walk; and, though the hemorrhage was not profuse, it was 
attended by such excruciating pain in the side, on being moved, that 
it was necessary to bring her bed into the parlor, where she remained 
several weeks. The hemorrhage and pain gradually subsided, and 
by the 1st of June, she appeared to have regained her usual health. 

"The second attack took place April 12th, 1839, and came on 
suddenly when making some unusual exertion while engaged at her 
toilet. The pain was so severe as to cause fainting, and was attended 
by vomiting, diarrhoea, retention of urine, tenesmus, severe bearing- 
down efforts, and slight uterine hemorrhage. These symptoms were 
mitigated by general treatment, without resorting to the catheter, or 
making a vaginal examination. She was confined to her chamber 
nearly three months under this attack, and was still suffering from its 
effects when I was consulted in her case. Her menses were irregu- 
lar ; her bowels frequently disordered ; she was unable to take her 
accustomed exercise, on account of a bearing-down pain and distress 
in the pelvic region, which was increased by exertion of any kind. 
Her husband informed me that since her last attack she had always 
suffered severely from sexual intercourse. 

"I considered these symptoms sufficiently indicative of disease or 
displacement of the uterus to call for an examination of the state of 
the parts. I found the uterus low in the pelvis, hot and swollen, and 
so sensitive as to preclude further exploration. Rest in a recumbent 
position ; bleeding; cupping over the sacrum ; and general antiphlo- 
gistic treatment, in ten days, produced so much relief that the patient 
declared herself better than she had been for more than a year. I 
then made a second examination, and found the engorgement, heat 
and tenderness much diminished ; but there was considerable pro- 
lapsus, and the uterus and vagina were morbidly sensible. 

" I was desirous that the patient should remain longer in the re- 
cumbent position, but the weather being warm, and confinement very 
irksome, I introduced a gilt-ring pessary, and sent her into the 
country. 

" Mrs. N returned about the middle of September. She in- 
formed me, that for three weeks after the introduction of the pessary, 



PREGNANCY (TUBAL). RETROVERSION. 229 

she felt unusually well ; she was able to stand and walk without suf- 
fering, and the distress in the pelvic region was much mitigated ; — but 
about that time, when using considerable exertion, she felt the instru- 
ment move, and it continued to trouble her until it came away. After 
the displacement of the instrument, her old symptoms returned, though 
for a time she was better than before its introduction. 

"After keeping the patient quiet a few days, I made another exami- 
nation ; — all morbid sensibility of the parts had now subsided, so as 
to admit of a full exploration, and, for the first time, I detected in the 
hollow of the sacrum, a round, hard body, with a deep indentation 
between it and the lower part of the neck of the uterus. 

" It was difficult to decide whether this was a tumor, or the fundus 
of the uterus bent down in that position ; but after a careful examina- 
tion, I was disposed to regard it as the latter, though it was much 
lower and more prominent than I should have expected from the 
situation of the os tincse, which was not more anterior than is usual in 
simple prolapsus of an equal degree. 

"After pressing up the uterus as far as I could, I introduced a gilt- 
globe pessary under the fundus, hoping it would gradually restore the 
organ to its proper position, and that if it came away, the patient could 
replace it herself, which was important, as those repeated examina- 
tions were very disagreeable to her. 

" The globe pessary was retained but a short time, and as it caused 
considerable pain and uneasiness during its retention, the patient was 
unwilling to have it again introduced. 

" At the suggestion of Professor Horner, of the University of Penn- 
sylvania, I next placed the patient on her knees in the bed, with her 
head and shoulders as low as possible, and introduced an instrument 
into the rectum under the fundus of the uterus, and by that means, 
assisted by its own gravitation, endeavored to dislodge it from its posi- 
tion. In this manner I succeeded in pressing the uterus up much 
higher than before, and after again introducing a ring pessary I re- 
quested the patient to remain quiet for a few days. This ring kept 
its position two weeks, and was productive of much relief, but it then 
came away, and the unpleasant symptoms returned. 

" This process of pressing up the uterus and introducing a pessary, 
was repeated several times; and it was found that a ring pessary was 
the only kind that was of any advantage, for while a ring retained 
its proper position, the patient was comparatively comfortable. This 
relief, from the use of a ring pessary, appears remarkable, when, after 
death, it was discovered in what manner the uterus was bound down 



230 PREGNANCY (TUBALJ. — RETROVERSION. 

to the rectum; there is, however, no doubt of the fact, and it may be 
explained by supposing that the anterior wall of the rectum was 
pressed forward and upward, or the adhesions stretched. 

" The difficulty of retaining the ring in its proper position, however, 
seemed to increase ; rings of silver gilt, glass rings, ivory rings, 
rings of hard wood, such as ebony and lignum vitse, and rings of gum- 
elastic were all tried, but the gilt rings were found much the best. 

" Discouraged by my want of success in the treatment of the case, 
I sought further counsel, and Professor Hodge of the University of 
Pennsylvania saw her with me, July 10th, 1841. On examination, 
he readily detected a retroflection ; a displacement of the uterus with 
which he was familiar, and which he calls a retort uterus from the 
fact that the uterus is bent on itself in the form of a retort. 

"He proposed the introduction and persevering use of a pessary of 
a peculiar form, which he has successfully used in many cases of the 
kind; I had an instrument made after his pattern, and introduced it; 
but it was not of the proper size, and caused considerable discomfort, 
which the patient attributed to the form of the instrument, and to my 
regret, was unwilling to have another one of the kind used. 

"During the following five years, she pretty much abandoned medi- 
cal treatment, except that, whenever her sufferings became unusually 
severe, she applied to me, when by pressing up the uterus and intro- 
ducing a ring, she would be much relieved for a time. Several other 
physicians were consulted in the case, but nothing important or novel 
was suggested. 

OS 

" Her symptoms gradually grew worse, and in July, 1847, 1 visited 
her, and found her confined principally to her bed; she appeared 
slightly emaciated; her brilliant color was gone, and she suffered 
severely from sickness of the stomach. She informed me that after 
passing her monthly period about three weeks, she had had a slight 
show, which had returned every few days for the last two weeks ; mak- 
ing about nine weeks from her last regular monthly period. On making 
an examination, I found the uterus occupying the same position it had 
heretofore done, and somewhat larger than before, but apparently not 
larger than an ordinary unimpregnated adult uterus. 

"I declined adopting any active treatment without assistance, and 
suggested Professor Meigs, of the Jefferson Medical College, who saw 
with me on the 17th of July. Dr. Meigs was sanguine, after exam- 
ining the state of the parts, that the uterus could be restored to its 
proper position, notwithstanding the length of time it had been dis- 
placed. 



PREGNANCY (TUBAL). — RETROVERSION. 231 

"He came next day prepared with an instrument to press up the 
fundus of the uterus, and with some small gum-elastic bottles, of the 
kind recommended by Hervez de Chegoin, in the hope that by gra- 
dual pressure in this manner we might succeed in restoring the organ 
to its proper position. 

" The patient complained of much pain when the doctor attempted 
to press up the uterus, though but moderate force was used. I filled 
the bottles with curled hair, which I found to answer admirably on 
account of its elasticity, and introduced one of them carefully be- 
tween the perineum and the fundus of the uterus. It gave no pain, 
and was retained without inconvenience, and appeared as though it 
would fulfil the indication. 

"I kept her in her bed a few days, after which she rode out occa- 
sionally, and once walked several squares. 

" On the evening of the 5th of August, after using much more ex- 
ertion than she had done for several months, the ball was forced away, 
and she was attacked with severe bearing-down efforts, so that it was 
a considerable time before she could be removed to her chamber. 
After she had been carried to her bed, I made an examination, and 
found the uterus at the os externum, and the bearing-down pains so 
severe as to threaten its expulsion from the vagina. 

" After administering an anodyne enema, and in some measure 
tranquilizing her system, I succeeded in pressing the uterus up to its 
former position, and introduced the gum-elastic ball at her own re- 
quest, as she said she felt safer and more comfortable while it was in 
situ. 

" The patient was unable to leave her chamber, and seldom her 
bed from this time ; and she often passed whole days and nights in the 
most awkward positions because the least motion increased the pain 
beyond endurance. Her stomach became so irritable that it was sel- 
dom anything would be retained in it even for a single hour. She 
became weak for want of nourishment. The most excruciating neu- 
ralgic pains pervaded every part of her abdomen, so as to preclude the 
possibility of any examination either externally or per vaginam ; and 
to increase the difficulty of diagnosis, she became tympanitic. 

" The w T ise women of the neighborhood said she was in the family 
way ; but of this we were not satisfied ; and Dr. Meigs, who placed 
considerable reliance on the appearance of the nipple, examined her 
breasts carefully, and there was not the slightest change of the areola. 

"An anodyne enema was administered every evening, but her nights 
were generally sleepless, and she gradually grew worse till the 19th 



232 PREGNANCY ( TUB AL).— RETROVERSION. 

of August, when I was obliged to leave the city for a few days. My 
friend Dr. Jewell attended her for me, and has furnished me with the 
following notes of the case:" 

"My first visit to Mrs. N. was made on Thursday, August 19th, at 
the request of my friend Dr. Yardley, who was to be absent from the 
city for several days. 

" Her condition, when I saw her, was anemic ; countenance thin, pale 
and sallow, expressive of long-continued and wasting disease; pulse 
sharp and frequent; abdomen tympanitic and exceedingly tender to 
the touch ; tongue clean and moist ; stomach so exceedingly irritable 
as to reject all nourishment and medicine, craving only ice, which, 
however grateful for a moment, afforded no relief. All her suffering 
was directed to a most excruciating pain in the left iliac region, ac- 
companied with extreme gastric distress, which symptoms had been 
in existence and increasingly so, for several days. 

"Fomentations of brandy and spices were applied to the abdomen, 
and various anti-emetics and sedatives were ineffectually tried for the 
vomiting. 

" In the afternoon, the symptoms being more aggravated, twenty- 
five leeches were applied over the stomach, and an enema of forty drops 
of laudanum in a gill of warm flaxseed tea thrown into the rectum. In 
the course of the night the gum elastic ball pessary, which had been 
introduced by Dr. Yardley, for the retroversion of the womb, came 
away during an effort to vomit, and was not replaced. 

" Friday 20th. Found her very weak and exhausted, with some 
slight relief from pain and vomiting ; expressed herself to be easier, 
but dreaded the return of the severe suffering she had experienced the 
day before. Was troubled with flatulency and slight oppression at 
the prsecordia. Directed the effervescing draught, with thin arrow 
root, in small quantities, and to be frequently repeated. The fomenta- 
tions to be continued as yesterday. 

" In the afternoon was sent for in haste — that Mrs. had convul- 
sions. On my arrival at her bedside, I found her in a collapsed con- 
dition, insensible, extremities cold, pulse and breathing scarcely per- 
ceptible, and her whole appearance completely blanched. By the 
persevering help of stimulants and artificial heat she gradually re- 
vived. 

"I learned from the family, that previous to her insensibility, she 
had complained of an agonizing pain in her left side, and an increase 
of sickness at the stomach, and in a few moments after went into con- 
vulsions. 



PREGNANCY (TUBAL). RETROVERSION. 233 

" So forcibly was I struck with her bloodless condition at this time, 
I remarked to her husband, that she had all the appearance of one 
who had lost a great amount of blood from flooding. 

" Being comfortably restored, before I left I ordered her brandy and 
water ; ice in small and repeated doses, with essence of beef; and to 
repeat the enema of laudanum and flaxseed tea if the pain returned, 
together with the following prescription in doses of twenty drops every 
hour: 

B. — Solut. sulph. morph. £i ; 
HofT. anod. liq. 3ij. 

"During the three following days, the vomiting continued with very 
little abatement. Every attempt to administer nourishment or medi- 
cine was indomitably resisted by the stomach, with the exception of 
the brandy and the morphine solution. On each successive day an 
anodyne injection was given, to subdue the attacks of pain in the left 
side. Her pulse in the mean time was feeble and frequent, her coun- 
tenance blanched, and her whole condition so much exhausted as to 
afford but slight hope of her recovery. On Tuesday, 24th, however, 
there was an apparent amendment in her case; her pulse began to 
react, she was able to retain a little nourishment, the vomiting had in 
a great degree subsided, and her expression was, "I feel comfortable." 
Her bowels not having been open for several days, I ordered her a 
turpentine enema, to which they responded readily, though not freely. 

" Wednesday, Aug. 25th. Had passed an easy night, but without 
much sleep ; upon the whole she had improved, was cheerful, had 
taken a cup of tea and had eaten some calf 's-foot jelly ; the tenseness 
and tenderness of the abdomen had subsided. I could make consid- 
erable pressure without causing either pain or sickness, and for the 
first time I was able to detect a tumor in the left iliac region, upon 
which spot, however, she could not allow pressure without acute pain. 

"I felt quite encouraged with her appearance and the improvement 
in her symptoms, as did also her friends. Feeble hope was given 
that she might be restored. She asked for a peach, w 7 hich was allowed 
her, and I left her in good spirits. 

" It was near 3J o'clock, P. M., when I was summoned by a hasty 

messenger, that Mrs. was dying. On approaching her bedside, 

which was surrounded by weeping friends, I found her lifeless. 

"I learned that she continued as well and as cheerful as when I left 
her in the morning, up to 3 o'clock, when she was suddenly attacked 
with violent pain, followed by a convulsion, which in a few minutes 
ended in death." 



234 



PREGNANCY (TUBAL 



-RETROVERSION. 



Having inserted the foregoing account of Mrs. N 's case, by 

Drs. Yardley and Jewell, it only remains for me now to say, that the 
necroscopic examination of the body of this unfortunate lady was 
made by Dr. Ellerslie Wallace, in presence of Dr. Jewell and the 
author of this article, on Friday, August 27, 1847. Upon exposing 
the contents of the abdomen by a crucial dissection, and looking 
downwards into the excavation of the pelvis, there was discovered a 
great quantity of coagulated blood and serum, which being removed, 
the uterus was observed to extend across the pelvis from front to rear, 

Fig. 70. 




PREGNANCY (TUBAL). RETROVERSION. 235 

lying horizontal in the excavation, and covered by the left Fallopian 
tube, which was turned over from left to right quite across the pelvis 
coincidently with the transverse diameter. The tube was enor- 
mously enlarged, having been converted into a sac which contained 
a foetus of near three months, developed in a tubarian gestation. 

The uterus being measured, was a little more than four inches 
long, and at the broadest part three and three-fourth inches wide. 
The child-bearing Fallopian tube could be lifted up from where it 
laid upon the front surface of the womb — no inflammatory attach- 
ment having as yet been formed to bind them together. Upon lifting 
the tube-sac off the uterus, and then attempting to raise the fundus 
uteri out of its retroverted position, it was not possible to succeed, in 
consequence of the adhesive bands and bridles that bound it to the 
lower part of the sacrum. When these adhesions had been divided 
by the scalpel, Dr. Wallace could lift the fundus out of its bed, and 
reposit the womb. This I had been unable to effect during Mrs. 

N 's lifetime, either with the hand or with Hervez de Chegoin's 

caoutchouc pessary. I was not surprised to find the fundus glued in 
this manner to the lower part of the sacrum, for I had, in June, an- 
nounced to Dr. Yardley my belief that it was adherent — an opinion 
founded upon the firm resistance of the tumor to all my attempts to 
reposit it. I may remark here, that I believe the womb might have 
beemgot out of its false and adherent position by means of the caout- 
chouc pessary, by slow and cautious proceeding, had not the tubal 
pregnancy unhappily supervened. I suppose that the adhesions might 
have been gradually broken or absorbed under the elevating power 
of M. Hervez's method. 

The rupture of the tube had occurred near its outer end, which 
from its being turned over and laid upon the prostrate womb, was 
found nearer the right than the left ischium. Through the edges of 
laceration in the tube-sac, one of the feet of the embryon was pro- 
truding. The uterus and its appendages were removed with consent 
of the friends. 

Upon laying the uterus open, it was found to be filled with a decidu- 
ous mass and with bloody slime. The cavity was somewhat enlarged, 
but the paries of the uterus w T as very thick, like that of a uterus con- 
tracted after delivery. The tube was now laid over to the left, its 
natural position, and opened; whereupon it disclosed the embryon, as 
in the figure, which was taken by Mr. M'llvaine ad vivum. The de- 
ciduous membrane is seen in the cavity of the uterus, its edges being 
laid over on the cut surfaces. 



236 EXTRA-UTERINE PREGNANCY. 

I regard the case as an interesting one, from its showing the 
presence of its decidua in utero in a tubal pregnancy, and more 
especially, as presenting an example of adherent retroversion ; and, 
perhaps not less so, as exhibiting tubal pregnancy in a woman with 
adherent retroversio uteri. 

Extra- Uterine Pregnancy. — I have met with three cases of 
extra-uterine pregnancy in the tube, all of which proved fatal about 
the third month, and I should expect the death of the patient to take 
place at or before the third month in any case, since it is improbable 
that the tube can ever furnish the material for a matrix longer than 
during some ninety days, at which time the tube-sac must become so 
much thinned and extenuated by its expansion as to burst. The rup- 
ture of the tube will be attended with fatal hemorrhage because, being 
the seat of gestation, it has become highly vascular, in order to the 
carrying on of the gestation within its walls. I do not believe that 
a tubal pregnancy will ever be suspected until it has burst and begun 
to bleed. One of these cases I have just related, as drawn up by Dr. 
Yardley, under the head of retroversion. 

If a woman should experience the signs of pregnancy, as to change 
of the aureole, as to nausea, pica and malaccia, as to growth of the 
breasts, extraordinary sensation within the pelvis, &c, and thereupon, 
when having attained to the middle of the second or to the third 
month, be seized with horrible pain inthe hypogastrium and pelvis, turn 
pale, lose the pulse and faint — I should suspect the rupture of a tube- 
sac of extra-uterine pregnancy. It is true that the above symptoms 
might be expressions of affections of the ureter, or perhaps of the 
bowel; but, in case they should continue and increase, with signs of 
concealed hemorrhage, so as to leave no doubt of imminent death, I 
think the diagnosis could not be other than a ruptured tube-sac of 
gestation. 

Such a diagnosis w r ould not lead to any hopeful therapeutic or chi- 
rurgical intervention, for nothing is to be done in these melancholy 
cases beyond the adoption of mere palliative measures. No man 
would be mad enough, under such diagnostic, to perform a gastrotomy 
operation. 

Case. — I had some years ago, a young woman under my care who 
supposed herself to be pregnant some two or three months. One morn- 
ing she took the broom to sweep her chamber-carpet, when suddenly 
she felt agonizing pain in the left iliac and pelvic region, which 



TUBAL PREGNANCY. 237 

extended through the belly. She fainted and became mortal pale 
and pulseless; the agony was terrible. I supposed she had ruptured 
the sac of a tubal pregnancy. She expired in the course of a few 
hours, with all the symptoms of hemorrhage in the abdomen. I could 
not obtain permission to examine the body. 

Case. — I saw another case which I shall relate in this place as 
follows : 

Mrs. , aged thirty-two, a healthy woman, mother of four 

children, was in excellent health on Sunday, October 7th. At six 
o'clock in the morning, she was singing and playing with her chil- 
dren. At seven o'clock, her husband, who was sick up stairs, heard 
her ascending the stair-case and groaning heavily ; when she entered 

his room, she appeared alarmingly ill. A physician, Dr. , was 

sent for, and found her with a pulse one hundred and forty ; in violent 
pain, extending from the top of the thorax on the right side, quite 
down to the iliac region. He attended her all day, applied a blister 
to the right side of the belly, gave a cathartic, &c. She passed a 
dreadful night, but was easier at eight o'clock next morning ; the 
pulse then one hundred and twenty. He left her for a short time, 
but found her worse on returning to the house. I was sent for, and 
arrived at half past two o'clock. She appeared to be dying at the 
time of my arrival. As she had vomited very much, and had a most 
excessive tympany, with violent pain in the whole belly, she got an 
enema, which brought off a great deal of stercoraceous matter, with- 
out sensible relief. In half an hour she said, " Raise me up — my 
breath is leaving me." I raised her a little on the pillows, and she 
swooned and died. Twenty hours after death, I opened the abdo- 
men and found it filled with about thirty ounces of blood, and bloody 
serum. The whole pelvis was filled with coagula, and a great quantity 
of blood was among the bowels. 

This blood came from a ruptured left Fallopian tube, which con- 
tained a foetus of six or seven weeks. The ovarium was somewhat 
enlarged. The womb had a deciduous lining, and the canal of the 
cervix was filled with a claret-colored mucus or lymph. The womb 
was larger than a non-gravid womb, though not a great deal larger. 

I have not had under my care any cases of ventral or abdominal 
pregnancy, though I have had opportunities to witness the examina- 
tion of bodies of persons perishing from this dreadful accident. I shall 
merely express some doubt that I feel as to the propriety of any gas- 



238 SIGNS OF PREGNANCY. 

trotomy operations in such cases, save mere incisions for the escape 
of the contents of the suppurating sac and the remains of the foetus. 

I refer the Student to the records, for samples of life not only con- 
tinued long after the complete development of the abdominal foetus, 
but of good health enjoyed notwithstanding. The late distinguished 
incumbent of the chair of Midwifery in the University of Pennsylva- 
nia, published an account of a lady who carried out a normal preg- 
nancy, notwithstanding she had in the abdomen an extra-uterine 
foetus which she carried many years. 

Signs of Pregnancy. — I have been, on several different occasions, 
both vexed and amused upon observing how prone are some medi- 
cal practitioners to overlook the signs of pregnancy even in married 
women, their patients. 

One gentleman, of great experience, tapped a woman for ascites — 
but his trocar went into the gravid womb and penetrated the shoulder 
of the foetus. She fell into labor and recovered of the accident; the 
child had the mark of the trocar on his shoulder. Many instances of 
the strangest oversight have occurred within my range of observation ; 
instances in which the size of the belly, the married state of the pa- 
tient, and the obvious evidences of gestation as well as its probability, 
ought not to have been overlooked, nor mistaken for diseases requir- 
ing troublesome, disgusting, or dangerous therapeutical prescription. 

The safest rule would be to suppose every married woman of the 
proper age, with suspension of the catamenia while not giving suck, 
as pregnant, and to treat her as gravid until convinced of the contrary. 

Let the Student imagine for a moment, how very disagreeable must 
be the reflections that follow the clearing up of so egregious an error 
as that of administering powerful emmenagogues to married women, 
who, nevertheless, would not miscarry ; or who, now and then, are 
found to miscarry under such a diagnosis. 

The signs by which a woman knows herself to be pregnant are, 
the cessation of her regular menses, and the subsequent enlargement 
of the abdomen, the movements of the foetus, certain constitutional or 
local disturbances or disorders, and modifications of the mammae. 

A married woman, who has been well regulated, suspects that she 
has conceived, if she fails to menstruate at the proper term; but this 
cannot be considered as conclusive evidence of conception, since 
so many and such various causes are found to obstruct and avert the 
regular course of the menstrual function. A second failure, espe- 
cially if it be not accompanied with any signs of depraved health, 



SIGNS OF PREGNANCY. 239 

renders the suspicion still more valid ; while after a third and fourth 
omission, the change of form, and at last the perceptible motion of the 
embryo put all doubt to flight. I may say, however, with great con- 
fidence, that the audible or visible movements of the foetus afford the 
only true and infallible signs of the existence of pregnancy. 

There are many accidental or correlative signs which establish 
probability of the existence of pregnancy: among which I may men- 
tion, nausea and vomiting; a gradual increase or development of the 
maramse; a change of the areola of the breast, which becomes more 
protuberant or elevated, and acquires a dark brown hue, which is 
much relied upon, especially in first pregnancies. The nausea is 
mostly found to occur in the morning, and is attended in some indi- 
viduals with a distressing heartburn, and a salivation or spitting of 
saliva. Some people are affected with gravel, or dysury, from the 
extension of irritation to the neck of the bladder, or from pressure of 
the enlarging womb upon the posterior surface of that organ. An 
irritable state of the temper indicates it in some women, which is at- 
tributable to the general malaise that must attend the gastric embar- 
rassments which the early stages of pregnancy are so commonly found 
to produce. Toothache, earache, styes on the eyelids, morph on the 
skin, a dark aureole around the eyes, and strange unaccountable 
longings or appetites, are also signs of pregnancy, rather to be noted 
after pregnancy is fully ascertained, than to be depended upon as 
sure evidences of its existence. 

By means of the Touch, pregnancy may be pretty surely ascertained, 
before quickening has taken place, but not surely. By the Touch 
we can readily learn that the womb is enlarged, altered in form, and 
contains something; but I do not see how any physician can absolutely 
aver what that something is, unless he can perceive a spontaneous 
motion in it; so that even the ballottement, or tilting the embryo upon 
the point of the finger, does not furnish, to my mind, any sure evi- 
dence that the tilted body is an embryo. I adhere, therefore, to the 
opinion I have already expressed, that we have no certain signs of 
pregnancy except those derived from the visible, palpable, or audible 
motions of the child. 

Auscultation, either by means of the stethoscope or the direct 
application of the ear to the abdomen of the woman, enables us to 
perceive two very distinct sounds, one of which is the beating of the 
heart, and the other is that which has been called the placental 
souffle, bruit de souffle, or bellows-like sound ; the latter being occa- 
sionally attended with a sound like the cooing of a dove. Whenever 



240 SIGNS OF PREGNANCY. 

we can distinctly hear the beating of the foetal heart, so as even to 
count the number of its pulsations, all doubt must be at an end. 
The placental sound, or the souffle, is a very distinct sound, which 
has been supposed to indicate not only the presence of a foetus, but 
also that it continues to live, the rushing or blowing sound being said 
to always cease as soon as the foetus expires : it is said to be, in some 
way not yet sufficiently understood, connected with the movement of 
the blood in the placenta, and to cease, of course, with the cessation 
of that movement, which is itself dependent on the systole of the 
foetal heart. 

Upon a more, scrupulous inquiry as to the value of the bruit de 
souffle, in the diagnosis of pregnancy, it has been found that the ear- 
lier opinions of it were erroneous, and I believe that there are few 
w T ell-informed physicians to be now met with who give it even the 
smallest portion of their confidence in the unfacile discriminations that 
they are sometimes charged to make. It is not to be doubted that the 
sound is produced by the rush of blood in vessels, and in my opinion, 
sustained by very long practice in obstetric auscultation, it depends 
upon the motion of blood in the iliacs and hypogastrics. I have cer- 
tainly heard the same sound after delivery as before the child was 
born ; and I have heard it, as dependent upon pressure by tumors 
within the abdomen. Hence I have not the least confidence in it as 
an object in obstetric auscultation. The sounds of the foetal heart 
need never be mistaken. They can be detected at the fourth month, 
when the opportunity is good. M. Depaul has heard them much 
earlier. To look for them earlier than the fourth month is, however, 
in general, merely to lose one's time and find a mortification. 

It is perhaps, on some accounts, of less consequence to be able to 
ascertain the existence of pregnancy in the married than in the un- 
married woman. The lapse of twenty weeks, and sometimes of six- 
teen weeks, makes it surely known ; and the married woman, who has 
no motive to keep it a profound and important secret, readily imparts 
a knowledge of her situation, or her suspicions relative thereto, to the 
physician, or her friends. Not so with the unmarried female, whose 
reputation depends upon the concealment of her misfortune, or her 
crime. I have frequently been very sorely embarrassed by uncer- 
tainty as to the condition of a patient whose ruddy cheeks and embon- 
point seemed quite incompatible with a suppression of the catamenia, 
and whose complaints of aches and pains might possibly be merely 
assumed as a means of deceiving the medical adviser. Physicians 
are frequently applied to by the unfortunate or guilty for relief from 



PREGNANCY AUSCULTATION. 241 

"obstructions," when the applicant has only a design to obtain some 
powerful deobstruent or emmenagogue, which may serve to procure 
an abortion, that she knows no honest or respectable medical practi- 
tioner could be induced to procure, for any pecuniary reward what- 
ever. I hold it, therefore, to be a duty, in all cases, or ranks, to 
compare the complaints of amenorrhea with the appearance of the 
patient, and if some evident malady does not accompany the supposed 
suppression, to withhold all medical aid, until time or necessity dis- 
close the indications that are to be fulfilled. In physic, nothing 
should be taken for granted. It is too much to expect that a female, 
who has it at heart to conceal her pregnancy, will confess it to a 
medical man. Experience teaches us the very contrary. 

Case. — I was requested some time since by a lady to visit a favorite 
servant, whose situation excited her apprehension, as she had failed to 
menstruate for the antecedent seven months, and was already consider- 
ably swollen with something like dropsy. Being directed to the young 
person's apartment, I found her in bed, covered up to the throat with 
bed-clothes, but the face that peeped out from above them actually 
shone with ruddy health, or agitation, or both. The pulse was natural, 
the tongue clean, the respiration normal, and the entire physiognomical 
expression as healthful as possible. She informed me that she had a 
stoppage of the courses for the last seven months, and felt very bad, 
and was now alarmed at a swelling of the stomach, which had in- 
creased greatly of late. Suspecting that she had an important secret, 
I asked some questions about pains in the stomach, and upon per- 
mission obtained, placed my hand on the abdomen, being almost cer- 
tain that I should feel the motions of a foetus; but, however long I 
held my hand on the abdomen, no movement of the child could be 
felt; so that, although I was certain she was pregnant, I was as 
yet unprepared to tell her so. I at length got permission to apply the 
ear against the side of the abdomen, and distinctly heard the placental 
souffle, and afterwards the stroke of the foetal heart. Upon this assur- 
ance I told her she was pregnant. " If I am," she replied, "I wish 
God may strike me dead!" and continued, with much temper and 
even passion, to declare that I maligned her and slandered her. I 
was obliged to leave her without the least assent, on her part, to my 
diagnosis, although she knew perfectly well that I spoke only a truth 
with which she had been long acquainted. She went out of town, 
and was confined in the country with a fine boy. Many examples of 
similar perverseness, in denying pregnancy, the signs of which were 
perfectly plain to me, and ought to have been obvious to the most 
16 



242 PREGNANCY AUSCULTATION. 

careless observer, have fallen under my notice; so that I deem it a 
solemn duty, previously to the exhibition of emmenagogue medicines, 
to ascertain that some signs of disordered health are present, in order 
that I may not commit the unpardonable fault of provoking an abor- 
tion, instead of removing a morbid obstruction of the catamenia. 

Let me warn the young beginner here, to take special care, in his 
diagnosis, that he shall first know the woman to be pregnant before 
he dare venture to say so. How could a gentleman commit a more 
unpardonable, or more insulting error ? 

I might here abstain from any further enumeration of the signs of 
pregnancy ; for I am accustomed myself to decline giving an opinion 
in any case, until I am sure that I cannot be mistaken, which I never 
can be when I hear the foetal heart, clearly and distinctly repeating 
its beats in the womb. 

Quickening is not a sign to be depended on; for the woman may 
perceive it, when the physician cannot. Her convincement is not an 
equivalent for his own convincement. Even the sensible motions 
felt upon palpation of the abdomen may deceive both the woman and 
the doctor. Multitudes of such deceptive cases are met with in a long 
career of practice. I have seen a woman who had the sensible 
motions of a child in her belly, though she had given birth to a foetus 
at full term only six weeks before, and several physicians who exam- 
ined her declared the motions to be caused by a child. Yet her cervix 
uteri was an inch long in the vagina, and the abdomen so soft as to 
enable one to push his hand down so far as to feel the spinal column. 

Many of my patients have engaged their monthly nurses and called 
me in, who, when I arrived, were found to be troubled with tympanitis 
only. Tenues in auras evadit. — See certain cases in my Letters to the 
Class, under the article Tympanitis. 

The toothache, the ephelis, the hordeolum, nausea, salivation, pica, 
pouting of the navel, and even milk in the breasts, are merely inferen- 
tial signs, and are by no means to be depended on. I repeat that I 
can rely only on the heart's motion heard in auscultation, and that 
sign cannot be detected until the fourth month. This is the rule ; the 
exceptions, few in number, are those in which it has been found in 
the pregnant woman as early as three months and ten days. 

Depaul, Traite Theorique et Pratique a 1 ' Auscultation Medicate, p. 

248, gives us the following relation. Case. — " Madame T , 

who has already borne several children, had her courses on the 10th 
to 15th April. From the 17th to the 20th of same month, she co- 
habited with her husband ; he then left Paris on a journey of a fort- 



PREGNANCY AUSCULTATION. 243 

night. Upon his return early in May, he found his lady confined 
to bed with the early symptoms of a typhoid fever, which in a 
few days became perfectly well marked, and continued twenty-four 
or twenty-five days. Her convalescence required a lapse of time 
nearly as long; and no sexual relation occurred until after her 
recovery. Nevertheless, upon the first of August following, as her 
courses had not reappeared, I was requested to see her with a view to 
determine whether this retention, which was very naturally attributed 
to the severe disease she had lately suffered, might require the employ- 
ment of certain remedies for its cure. I confess, that I was at first 
inclined to give up the idea of a pregnancy, begun antecedent to the 
commencement of the typhoid fever. I was little inclined to suppose 
its existence, computing it from the new sexual relations succeeding 
her convalescence; but the examination per vaginam, enabling me 
to detect a notable development of the volume of the uterus, I fell 
back upon the first opinion, of the propriety of which I became fully 
convinced, when, after having applied the stethoscope at various 
times upon the inferior region of the abdomen, I discovered the double 
pulsations, which were repeated 140 times a minute, while the pulse 
of the mother was only seventy-six. I could not hear the souffle 
uterin. Her confinement occurred in the following January." 

M. Depaul, if the above case is to be relied on, heard the double 
sounds 100 days, or three months and ten days after the fecundation 
had taken place. The pregnancy continued 174 days after the audi- 
tion of these foetal sounds by Dr. Depaul. 

Probably few such early detections will be made by all the readers 
of this paragraph. 

Inasmuch as I have spoken at length on the signs of pregnancy in 
my "Letters," I shall beg to refer the Student for further informa- 
tion, to that volume sub voce. 



PAET III. 

THE THERAPEUTICS AND SURGERY OF MIDWIFERY. 



CHAPTER IX 



LABOR. 



In coming now to this third division of our subject, or Midwifery 
proper, the Student ought to be informed that the practice of this art 
is one requiring not only a large amount of obstetrical or scientific 
information, but also a great deal of prudence and delicacy, as well as 
knowledge of the world; without which he will scarcely attain to any 
considerable eminence or happiness in the practice of it. From the 
foregoing imperfect statement of the anatomy and physiology of mid- 
wifery, subjects which, to be well described, would require several 
volumes rather than a few short chapters in this one, it will have 
been seen, that a great variety of considerations must precede the 
study of Midwifery proper; and that these considerations relate not 
only to the structure and functions of the living body, but also to 
every step in the development of that body, from the earliest dawn of 
its existence, up to the complete maturity of its powers and faculties. 

Such studies as these are in the highest range of philosophical con- 
templations. While they belong, perhaps strictly, to the dominion of 
Natural History, they can never be disconnected from a pure Meta- 
physics, since the laws of life and those of mind are one and the same. 
Again, so delicate and difficult, in point of conduct and conversation, 
are the duties of the accoucheur, that there is nothing short of abso- 
lute good sense and tact can carry a man without reproach or mis- 
fortune through a long career of this business. 

There have not been wanting very good writers to show that the 
whole of this study and practice ought to be confined to persons of the 
tender sex; asserting that the relations of the sexes ought not to war- 
rant those familiarities that are inseparable from the practice, by men, 



LABOR. 245 

of the Art of Midwifery ; and, in the world, at the present day, though 
it is admitted that the Surgeon accoucheur is an indispensable person 
in society, he is by many looked upon with a sort of doubt and dis- 
trust, on account of the very peculiar nature of his pursuits. 

It ought to be evident to the intelligent and ingenuous Student, that 
some fit preparation of the mind to the discipline of this Art is required 
as an introduction to the exercise of it; since, to go at once from the 
College, and without reflection, into the very questionable position in 
which he is about to be placed, shows, to say the least, a great want 
of prudence and forethought. 

Many clever men have made shipwreck of their hopes by the want 
of a little reflection as to the course they should pursue ; or by early 
abandoning themselves to professional habits, which, without the least 
intention on their part, have gradually assumed a tone of familiarity, 
which has been construed into impertinence, or downright insult. 

In my opinion, no woman can be placed in a sanatary condition 
compelling her to appeal to the aid of the accoucheur, without some 
sense of a mortified delicacy. If this be true, it is quite clear that the 
only reparation for, or the only means of obviating this unpleasing 
impression, consists in the exhibition to herwards, of the most pro- 
found respect and sympathy, proffered with a sincere conviction of 
the painful nature of her position, as well as the indispensable pro- 
priety and necessity of submission to it. 

A female possessed of ordinary sensibility will be less affected by 
the sacrifice of feeling she is thus compelled to make, if she be treated 
as an object of respectful consideration, than if approached with a 
light and indifferent address ; and while she finds her own pride less 
wounded, will be both more confiding in the wisdom of her physician, 
and grateful for his counsel or service, as well as respectful to and 
considerate of his calling and profession. 

The occurrences that befall in the course of an accoucheur's pro- 
fessional life, are many times of a nature to require at his hands 
secrecy, and good faith ; for he cannot but become the depository of 
many informations, in which are involved the reputation and even 
honor of persons, and the safety of most important interests. 

Let the Student, then, before he goes any farther, make his mind 
firm in the resolution to guard with good faith those secrets with which 
he may become acquainted as physician, or Surgeon-accoucheur. He 
ought beforehand to consider the meaning of the term professional 
secrets, and know that they are confidences made to his station as 
physician, and not to himself as a person ; for, of the vast number of 



246 LABOR. 

those which may be hereafter communicated to him, or discovered by 
him, not a tithe or a hundredth part of them would ever be his, but 
for his professional standing. If a man, therefore, is dishonored who 
reveals a secret communicated by a friend, how far more base is he who 
takes advantage of his professional standing to make public circum- 
stances that have been entrusted, so to speak, not to himself alone, 
but to the sacred character of the latrist. 

It is not in regard to grave and serious matters only, that he is 
called upon to be silent, prudently abstaining from acquiring for him- 
self and his brethren, the unenviable character of the babbler — even 
the most inconsiderable circumstances as to the sick, are confidences 
that ought not to be disappointed and betrayed. This is a just and 
true remark, and it is a rule that ought to be followed in all circum- 
stances and ages. The great Caliph Al-Mamun, as we are informed 
by Abul-Pharajius, in his History of the Dynasties, was a friend of 
science, and he exhibited his patronage, by fostering many learned 
men, among whom were some of our own profession. 

Among other of his medical favorites, was John Ocularius, whose 
duty it was to visit the Commander of the Faithful everyday, and that 
in his most private apartment, alone. 

The caliph gave him great honor, and allowed him a monthly sti- 
pend of one thousand gold sequins for his services. 

Upon one occasion, as the physician came out of his master's apart- 
ment, in passing through an ante-room, he was asked by one of the 
servants, " What is the caliph doing?" " He is sleeping," was the 
reply. But unhappily, this reply was communicated to the successor 
of Mahomet, whereupon the culprit was sent for, and brought before 
the chief of Islam. " What!" said he to the offender, "have I em- 
ployed you as my physician, and admitted you to my intimacy, in 
order that you should report to my servants as to my private occu- 
pations? Go out of my house." 

The poor medico, in telling this story, to account for his fall, added 
that the caliph never afterwards would admit him into his presence ; 
which was but the just punishment of a professional indiscretion. 

Let the Student reflect upon the punishment deserved by those who 
babble the concerns of families or individuals. John Ocularius was 
turned out of the court of Al-Mamun for merely saying that his master 
was asleep ! 

But, in addition to the quality of discreetness above insisted upon, 
the Student should firmly resolve to merit the appellation of Scholar — 



LABOR. 247 

a title far more honorable than that of mere knight, or nobleman, or 
minister of state. 

It is to the Scholar that the world is indebted for its preservation 
from its own violence and vices. It is to the Scholar that it is in- 
debted for good laws, for science, and for all the arts. The Scholar 
is the promoter of virtue, and decency, and good conduct, both by his 
precept and his example ; for it is to him that mankind turn their eyes 
to see what is wisdom, and virtue, and true liberty. All those who 
are not, by education, brought out of the bondage of ignorance, are 
slaves indeed ; slaves of lust, of superstition, and ignorance. Hence 
it is evident that the Scholar is the only real nobleman, and his no- 
bility becomes more and more exalted in the ratio of his elevation in 
virtue and knowledge, towards the fountain and source of all know- 
ledge and virtue. 

The Student ought not to rest satisfied with the bare intention to 
make himself equal, in skill and dexterity, to the common midwives 
of the country. He ought to be resolved to become fully acquainted 
with the dynamics of the generation-sphere ; by the irregular ope- 
ration of which, as Wigand says, the power of the uterus in labors 
is so often baffled, and its energies misdirected. If he studies well 
the therapeutics of midwifery, and practises them well, there will be 
no occasion to twit him with the reproach so commonly cast on the 
accoucheur, that when he is called in, " one or the other, mother or 
child, goes to the grave," to use the words of Wigand, which I can- 
not but quote in this place. " Gibt es keine gegend, keine stadt 
mehr, wo das Publikum es nicht anders w T eiss und gewohnt ist als 
dass, w T o ein accoucheur sein hand anlegt, wenigstens eins von 
beiden, das Kind oder die Mutter, darauf gehen miisse ? Kennen, 
wir jetzt keine Geburtshelfer mehr, die, wo sic hinzugerufen werden, 
keine andere Indication zu machen im Stande sind, als augenblick- 
lich mit Zange oder Faust, iiber den unschuldigen Uterus herzu- 
fallen, und ihn, wie einem Dieb und Spitzbuben der das Kind gestohlen 
hat, zu mishandeln?" " Are there not any districts or cities to be 
found, in which the public generally suppose that where a physician is 
called in, one of the two, mother or child, must be sacrificed ? — and 
are there no accoucheurs at the present day, who, being called to a 
case of labor, can discover no other indication of treatment than that 
of instantly, with hands, or with tongs, falling upon the innocent 
womb, to abuse and maltreat it as a thief, or robber that has stolen 
the child?" 

These words of Wigand are strong words ; let them sink deep into 



248 LABOR. 

the heart of the Student, for they are from the lips of as true and noble 
a Scholar as has in any age graced the annals of Medicine. Let the 
Student now enter upon his pursuit with a resolution to add something 
to the value of the art he is about to practice during his future life ; let 
him leave to the brethren, and to the world, some fruit or fruits of his 
observation, his reflections, or his experience. He is about to enter 
upon a life singularly arduous and toilsome, involving sudden and most 
painful responsibilities to individuals, and to society at large. He is 
doomed to sacrifice himself for his station. There are no vacations 
or holydays for him; and night itself is turned into day; for his occu- 
pations cease not with the setting sun ; his task is never done. More 
labors occur at night than during the day ; a circumstance that adds 
greatly to the onerous and distressing duties of the Accoucheur. 
M. Quetelet, of Brussels, in his treatise Sur V Homme et le Deve- 
loppement de ses Facultes, &c, t. i. p. 108, says that, being led by 
curiosity to inquire whether there is any connection between the 
hours of the day and the number of births, he employed in his calcu- 
lations certain results communicated to him by Dr. Guiette, who was 
then attached to the Maternity Hospital St. Pierre, at Brussels. They 
were collected during eleven years, from 1811 to the end of 1822. 
M. Quetelet communicated them to M. Villerme, who found them per- 
fectly analogous to results obtained at the Hospital de la Maternite, 
at Paris. 

In making out his tables, M. Quetelet adds a column showing the 
number of the still-born children, and a third column indicating the 
results obtained by M. Guiette in 1827 and 1828. 



Hours. 


Births, 


Still-born, 


Births, 




1811-1822. 


1811-1822. 


1827, 1323. 


After midnight 


798 


53 


145 


Before noon 


614 


51 


119 


After noon 


574 


59 


119 


Before midnight 


694 


55 


148 



Total 2680 218 531 

" These results show that births are more numerous at night than 
during the day; the ratio for the eleven years from 1811 to 1822, is 
1492 to 1188, or 1.26 to I ; and for the two years' results of Dr. Gui- 
ette, 1827, 1828, the ratio is 293 to 238, or 1.23 to 1 : hence, there 
are born at night almost exactly five children for four born during 
the day." 



LABOR. 249 

Dr. Buck, of Hamburg, came to nearly similar results. M. Que- 
telet sets up the following table of them : — 



Births. 


Winter. 


Spring. 


Summer. 


Autumn. 


Mean. 


After midnight 


325 


320 


291 


312 


312 


Before noon 


270 


252 


256 


216 


249 


Afternoon 


190 


136 


189 


235 


183 


Before midnight 


215 


292 


264 


247 


256 



These figures give the ratio of 1.31 to 1 for the night and the day. 
Particular observation shows, that at about the hours of noon, and 
midnight, the births are least numerous. Notwithstanding the ratio 
of night to day births is as above stated, it will happen, that of those 
referred to as day births, a very large number will require the counsel 
of the physician during the night. It is true, therefore, that his task 
is a severe one. With these remarks, I now proceed to treat of Mid- 
wifery, which is the art of assisting women in labor. 

Labor is the process by which the contents of the gravid womb 
are expelled; and the word is highly expressive of the fatiguing, 
violent, and painful struggles and efforts of the woman to overcome 
the obstacles to her deliverance from the uterine burden. Labor 
should commence, as we have already seen, at or about the two hun- 
dred and eightieth day from the last appearance of the menses, or 
the one hundred and fortieth day after quickening; and it may, in 
general, be expected to terminate without any artificial power or assist- 
ance, after a few hours of travail — the time being greater or less, 
according to the amount of the power employed, or the resistance to 
be overcome. The average duration of labor has been stated at 
four hours: I should think it greater. There are many examples of 
women in labor w T ho are completely delivered in ten minutes from 
the first perception of the signs of parturition: very numerous cases 
occur in which labor is protracted during twenty-four hours; while 
some of the patients are occupied three, four, and even five days, 
with continuous efforts to bring the child into the world. I have wit- 
nessed one labor of nine days' duration, and many of from three to 
five days. 

The essential element of labor is the contraction of the muscular 
fibres of the womb, the end or object of which is the evacuation of 
the uterine cavity, so that, the whole of its contents being ejected, it 
may return again to the non-gravid state, when it will measure from 
two and a half to three inches in length, about an inch and a half in 
width, and half an inch or three quarters of an inch in thickness; the 



250 LABOR. 

organ being, before the commencement of contraction, about twelve 
inches long by seven or eight inches in transverse diameter. 

As the os uteri is closed during pregnancy, it follows that the 
expulsion of the contents of the organ cannot take place until the 
orifice becomes sufficiently opened to permit the child to pass out; and. 
that there is also required for the purpose a sufficient dilatation of the 
vagina, and of the vulva ; in all which parts a greater or less de- 
gree of resistance or obstacle is found; which, taken in connection 
with the resistance afforded by the bony structures and the perineum, 
are generally the causes of a delay of several hours in the birth of the 
child, even where it presents itself most favorably to the openings 
through which it is destined to effect its exit. 

In a vast majority of cases, the powers of the womb alone are insuffi- 
cient to effect the delivery of the child ; and its birth is considerably 
aided by the efforts of the abdominal muscles, and the diaphragm, 
which are not only capable of making a direct expulsive effort, but, 
by presenting a point (Pappui for the contracting womb, can assist 
it, more efficiently to exert its own peculiar forces. The abdominal 
muscles and the diaphragm, acting alone, can push the point of the 
womb down low into the excavation, and hold or fix it there, while 
the fundus and body of the organ are propelling the ovum against the 
obstacles that stand in the way of its escape. Hence, although the 
essential element of labor consists in the uterine contractions, there 
are collateral dynamic elements of the process that greatly avail in its 
completion, and that ought always to be well understood, in order that 
they may be either called into action, or restrained, as the obstetrician 
may please to direct. Perhaps the best idea of the dilating pains of 
labor is, that the presenting part of the child is pressed against the 
circle of the os uteri, which, by the contraction of the body and fundus, 
is drawn upwards over it, so as to strip the womb up over its head, 
its body and its legs, until the whole is expelled from the os uteri. 

Cause of Labor. — The cause of labor, or, I should rather say, the 
cause of the onset of labor, is not well understood; although it is 
quite probable that it is to be found only in the inability of the womb, 
in any given case, to bear further distension. Labor begins from a 
necessity of the uterine constitution, and not from any ascertained 
degree of development of the child, which, whether large or small, is 
most likely to be born two hundred and eighty days after the last 
catamenial period of the mother; but may not be born until three 
hundred, or even more days have elapsed. The size of the child 



LABOR. 251 

is not found to bear a proportion to the excess of the duration of the 
pregnancy. It does, in fact, frequently occur, that the womb begins 
its contractile effort long before the expiration of the two hundred and 
eighty days; or, on the other hand, it fails to commence its contraction 
for several days after the two hundred and eighty have elapsed; but, 
whenever it does begin, it is because it will admit of no further or 
longer-continued distension. 

The theory by which Baudelocque endeavors to account for it, 
and which I have already explained, is, that there is a contest or 
antagonization betwixt the fibres of the cervix and those of the fun- 
dus and body of the womb ; that, in the early months of pregnancy, 
the fibres of the body and fundus yield to, while those of the cervix 
resist the distending force, until about the seventh month, at which 
time they also begin to yield, and continue to yield until the end of 
the ninth month. These fibres of the cervix may be regarded as the 
seats of the retentive, while those of the fundus and body are the seats 
of the expulsive faculty or power. At the ninth month they are ba- 
lanced, or antagonize each other exactly. At length, the development 
of the womb going on, those of the fundus become the more powerful, 
and those of the cervix and os uteri are developed, and finally so com- 
pletely opened as to allow the ovum to escape. This explanation is, 
perhaps, as good as any that could be offered; but, although human 
sagacity or reason may remain ever incompetent to the task of unfold- 
ing the secret forces on which the commencement of labor, or rather 
the completion of the utero-gestation, depends, it is perhaps not unwor- 
thy of remark, that, in the development of the gravid uterus and its 
contents, we behold a wonderful adaptation of parts to the purposes 
they are destined to fulfil ; since the growth of the child would, if 
continued indefinitely, make its delivery impossible, and therefore the 
Author of nature has, by a simple law, provided against such a fatal 
contingency; the womb, by that law, refusing to yield any further than 
is sufficient to allow the child to acquire a certain degree of magnitude 
and vigor, essential for its respiratory life, but not too considerable to 
prevent its birth from taking place ; and this perhaps is, after all, a 
sufficient solution of the problem. 

Subsidence of the Womb. — The term of utero-gestation and the 
commencement of labor may be supposed to be fixed, and rendered 
necessary in part, also, by the great distension of the abdominal 
muscles, and intolerable pressure upon and displacement of the parts 
contained within the abdomen. I know not what influence on the 



252 LABOR. 

production or excitement of labor may be exercised by the altered 
state of the abdominal muscles themselves; but it is, perhaps, not too 
much to infer that they do at length exert some considerable share 
of influence, by their constant or tonic contractile operation, in aiding 
the fundus and body to overcome the retentive effort of the os uteri, 
any yielding or relaxation of which tends to invite or provoke the 
contractile effort of the fundus. We see, at least, that, in the last 
days of pregnancy, the womb settles down with its apex in the Exca- 
vation, and the woman seems much smaller than she was before this 
sinking downwards of the uterine globe was perceived. Now, it may 
be asked what can cause this settling or sinking downwards of the 
womb, if it be not either the action of the abdominal muscles and dia- 
phragm, which have pushed it downwards, or the contraction of the 
womb itself? It is probable that both of these influences are, some- 
times, concerned in the matter; and at other times only one of them, 
and either of them ; for it happens that when the womb is much 
sunken, it in one case feels very hard and firm, as if its fibres were in 
a state of contraction or condensation ; whereas in another case it is 
soft and flaccid, notwithstanding it may be very much depressed into 
the excavation; no sign of actual labor being present in either ex- 
ample. The sinking downwards of the womb takes place, in some per- 
sons, several days before the first pains are felt. In such cases it must 
generally be regarded as wholly passive in the matter; it is forced down 
by the muscles, and not by any intrinsic action or power of its own. 

This is called the subsidence of the womb before labor comes on, 
and it is a sign of the approach of that crisis which monthly nurses 
and experienced women are acquainted with — and which it is proper 
that the Student should also be able to appreciate. 

Labor Pains. — The contractions of the womb take place at inter- 
vals, which are longer at the beginning, and shorter as the labor ad- 
vances. They last from fifteen to thirty or forty seconds, and, on 
many occasions, even longer. The intervals, at first, are from twenty 
to thirty minutes ; but as the irritation becomes more intense, the 
pains are repeated every five, three, and two minutes, and even every 
minute ; increasing in violence and duration until the organ is freed 
from its load. 

As to the duration and number of the pains, I said a little while 
ago that the average duration of a labor has been stated to be four 
hours. If this computation is a correct one, then it may be said that in 
the first hour the woman shall have a pain every twelve minutes, which 



LABOR. 253 

would give five pains for the first hour. If she should in the second 
hour have a pain every six minutes, she would have ten pains in the 
second hour : pains every five minutes of the third hour would amount 
to twelve pains ; and if she should be affected with them every three 
minutes during the fourth and last hour, she would suffer the pains 
twenty times in that period. So that twenty, twelve, ten, and five 
pains would make up the sum of forty-seven pains for the labor. The 
whole duration of the whole of the labor pains, supposing each one 
to last only twenty seconds, under this computation would be about 
fifteen minutes ; so that, in a labor of four hours the woman would be 
fifteen minutes under labor-throes, and three hours and three quarters 
without them. It is to be understood, however, that much pain and 
distress may be present, notwithstanding the womb is not actually 
contracting. 

This calculation refers, therefore, only to the state a woman is in 
when under the influence of a labor pain, and not to the other 
causes of distress, from pressure, distension, and the disparting of the 
textures in the pelvis. 

The pain felt in labor is owing to the sensibility of the resisting, 
and not to that of the expelling organs. Thus the sharp, agonizing, 
and dispiriting pains of the commencement of the process, which are 
called grinders, or grinding pains, are surely caused by the stretching 
of the parts that compose the cervix and os uteri and upper end of 
the vagina. They are rarely felt in the fundus and body of the organ ; 
and nineteen out of twenty women, if asked where the pain is, will 
reply that it is at the lower part of the abdomen, and in the back — 
indicating, with their hands, a situation corresponding to the brim of 
the pelvis, and not higher than that — a point opposite to the plane of 
the os uteri. 

When the pains of dilatation are completed, and the foetal presenta- 
tion begins to press open the whole vagina, the pain will, of course, be 
felt there, and is finally referred to the lower end of the rectum, and 
the sacral region generally. The last pains, which push out the peri- 
neum and put the labia on the stretch, will of course be felt in those 
parts chiefly. The painful sensation, under these circumstances, is 
represented as absolutely indescribable, and comparable to no other 
pain. 

The effect of the pain on the bladder and rectum might easily be 
foreseen ; but, even where they fail to excite the sympathetic action 
of those parts, the descent of the foetal head, which sometimes fills up 
the pelvic canal, as a cylinder is filled by its piston, must cause the 



254 LABOR. 

evacuation of the entire contents of the lower rectum and bladder of 
urine. 

The effects produced by the pains and efforts of labor upon the 
constitution are very striking. The mind, in the beginning, is anx- 
ious, irritable, fearful, and full of the most gloomy anticipations; but 
as the process goes on, and the expulsive efforts become more and 
more violent, it acquires courage and firmness and the most dogged 
resolution. The patient seems like one who has a task set for her, 
which she is resolved to execute as rapidly as possible ; and she there- 
fore bears the great pains of expulsion far more submissively, or rather 
courageously, than the small or dilating pains. 

The actions of the woman indicate pretty clearly, to the practised 
eye, the state of advancement of the process. Antecedently to the exit 
of the head from the os uteri, or its deep insertion into that circle, the 
voluntary efforts of the patient are confined to a violent grasping of 
things with her hands. She generally seizes the hand of a bystander, 
and squeezes it violently, or endeavors to twist or wring it, not pull it. 
Such an action always indicates a grinder, or a pain of dilatation ; but 
when an expulsive effort takes place, she not only grasps with all her 
force, but she pulls at anything in her reach; so that an experienced 
accoucheur generally can decide, upon entering the chamber during a 
pain, that the dilatation is or is not completed, by observing whether 
the patient merely squeezes or presses the hands of her assistants, or, 
on the other hand, whether she pulls them with great violence. 

This low position or situation of the presentation at length institutes 
a tenesmus, or bearing-down sensation, which is a desire to press with 
all the forces of the abdominal muscles, whatever exists within the 
pelvis, beyond the limits of the body. Tenesmus, is, in the beginning, 
controllable by the will, but when it has become exaggerated by the 
presence of the presenting part in the ostium vagina?, it does happen 
that no exhortation or fear is capable of inducing the woman to 
refrain from making the effort, in certain cases. Sometimes, however, 
the patient may be aroused from the all-absorbing tenesmic sense, 
and made to heed the urgent appeals of the surgeon to desist from 
efforts that endanger her. The urine and stool are generally expelled 
pretty soon after the commencement of the tenesmic pains of labor. 
But in some patients, the first signs of labor coincide with a disposi- 
tion to go on the close stool. 

In addition to the signs derived from the woman's voluntary actions, 
the practitioner can frequently decide upon the degree of forwardness 



LABOR. 255 

of the labor, by attending to the nature of his patient's expressions and 
moans, and her respiration. In the early stages of labor during the 
dilating pains, she either gives out her breath freely, with voice, or 
merely holds it, making use of no straining or bearing-down effort ; 
and even if she be here requested to strain or bear down, as at stool, 
she will resist, or cannot obey, the injunction. 

Women cannot bear down, at the very beginning of labor. 
Bearing-down means an effort to expel by contracting the muscles 
of the belly; but when the womb is full, its fundus at the scro- 
bicle, and its os at the plane of the strait, the recti muscles can- 
not expel, they can only hold or compress it. The same is true of 
the oblique and transversalis muscles. When, however, the fundus 
has descended low in the abdomen, having foilowed the os uteri 
which has by this time been pressed down to the bottom of the excava- 
tion, then the abdominal muscles can exert a vast expulsive energy. 
So that, when the os uteri is nearly or quite opened, and the expulsive 
pains alone operate, the woman not only holds her breath, but she 
makes use of the muscles of respiration to fix the thorax firmly, and 
then, in the most forcible manner, contracts the muscles of the abdo- 
men upon the womb. If she be now enjoined to desist from bearing 
down, she often fails to obey the injunction, because the tenesmus of 
labor, like that of dysentery, is irrepressible. The muscles that she 
employs in bearing down, after she has fixed the diaphragm and other 
muscles belonging to respiration, are the rectus abdominis, the external 
and internal obliqui, and the transversalis. Is it not clear, that while 
the fundus uteri is high up in the abdomen, the violent contraction of 
these muscles would have little effect in forcing the uterus downwards, 
but would rather compress the womb against the back part of the 
abdomen; while ; on the other hand, when the uterine globe has sunk 
low down in the belly, the operation of these abdominal muscles, as 
agents of expulsion, must become very great and cogent ? I have ever 
found it useless to urge a woman to bear down upon a grinding pain, 
and always feel it incumbent upon me to cause the nurses and by- 
standers to desist from exhorting the patient to bear down, in the early 
stages of labor ; an exhortation which they very kindly, but very un- 
timely, never fail to make. Such voluntary efforts cannot be benefi- 
cial in their influence on the labor, but they may become pernicious, 
in certain circumstances, where they not only tend to disorder the 
sanguine circulation, but very much and very early help to exhaust 
the strength. 




256 LABOR. 

I have placed here a cut, Fig. 71, which shows the state to which 
the cervix uteri must arrive before the full 
efficacy of the true expulsive, or bearing- 
down pains can become manifest. This is 
a cross section of the pelvis, with the womb 
and a part of the already dilated vagina. 
It seems that the cervix uteri has become 
almost cylindrical, from being a cone, as it 
was before labor began. The bag of waters 
is seen bulging out from the fully dilated 
orifice. The waters are nearly ready to 
give way — and, in fact, there are many la- 
bors in which, as soon as the crevasse in 
the membranes takes place, the child's head rushes rapidly through the 
orifice and descends to the very bottom of the excavation, or is even 
expelled by the same single pain. 

Constitutional Effects of the Pains. — Even leaving out of the 
question the exciting effects of the pangs and agonies of travail, we 
should naturally expect that the muscular exertions of the parturient 
subject would, as in violent exercise, greatly accelerate the circulation 
of the blood, and augment its momentum ; and we accordingly find the 
pulse grows more and more elevated as the efforts become greater and 
greater; the heart beats with increased violence, and the pulsations 
amount to one hundred and upwards in the minute ; even one hundred 
and twenty beats are not uncommon. The respiration becomes hurried 
in proportion, and of course the heat of the body tends to be developed 
pari passu with the augmentation of the circulation and respiration; so 
that fever would soon become intense, were it not that the most pro- 
fuse diaphoresis, chiefly from the upper part of the body and head, 
comes on to prevent the occurrence of what would, otherwise, become 
a dangerous fever, and in a few instances does become so. I have 
already taken occasion to remark upon this excited state of the vascu- 
lar system, that it is not to be deprecated except in those instances in 
which it goes beyond the just bounds. It is, however, always worthy 
of close observation, in order that its tendency to excess may be 
checked, by a free use of cooling drinks; by ventilation ; by lighten- 
ing the bed-clothes; by making the patient comfortable in her bed — 
removing wet sheets and heated pillows ; by an enema, or purge ; 
and lastly and chiefly, by the use of the lancet. 

The state of the mind is also worthy of a large share of the Accouch- 



LABOR. 257 

eur's regard. The most cheering and satisfactory assurances that the 
state of the labor will admit of, should be given, with a due observance 
of the truth. A woman will be more comforted and composed by 
being made certain that she shall be delivered in six hours, than by a 
promise which she does not fully believe, that half an hour more shall 
put a period to her anguish. No promises should be made, that may 
not be implicitly relied upon by the physician himself, as well as by 
the patient. One of the golden verses of Pythagoras says, sfiov ogxov 
— Keep thy troth. 

Outward Signs of Labor. — The signs of labor are those which we 
obtain from simply observing the woman's manner, and from hearing 
her own account of her symptoms ; or they are such as we obtain from 
the Touch, or examination per vaginam. For the most part the state- 
ment of the patient herself, or that of her monthly nurse, is taken as our 
sufficient early evidence, and we wait for a certain degree of manifest 
progress before we address ourselves in a more particular manner to 
establish the absolute diagnosis, which cannot be very certainly done 
without the Touch. 

Still, there may be observed the subsidence of the abdominal 
swelling, owing to the sinking of the apex of the uterus into the exca- 
vation, and in some measure, to an increase of tonicity in the whole 
organ. 

In most of the cases, the new vital intensity, set on foot, manifests 
itself by augmented moisture of the genitalia, and especially by a 
viscous mucus, that not a little resembles the white of eggs, which, 
moreover, is frequently stained with a little blood coming from the 
disrupted capillaries about the cervix uteri. This tenacious mucus 
is not yielded by the vagina, but always and only by the cervix. 

An increased tendency of the bladder of urine to expel its contents, 
also marks the beginnings of labors; and the rectum is favorably 
affected when the pelvic excitement prompts it to dejection of its 
contents. 

Nausea and vomiting are frequently met with in the lying-in room, 
as symptoms of commencing labor ; though it is true they mostly 
present themselves when the os uteri is about one-third dilated. 

Violent and protracted tremors of the body and limbs, with clatter- 
ing of the teeth, as in ague, are very generally observed, but they are 
unaccompanied with any chill or sense of coldness. 

Finally, pain in the back and hypogastrium, lasting about twenty 
seconds, attended with hardening of the uterine globe, and recurring 
17 



258 LABOR. 

at regular even intervals, is a sign much to be relied upon, though 
the vaginal taxis gives us the safest assurance by revealing the state 
of the os uteri. 

In general, we are accustomed to note, by a watch, the length of 
the intervals betwixt the pains, and to form an opinion of their intens- 
ity, by the gestures or moans, or other complaint of the woman. 

If the patient have reached her full term, we are free to announce 
from these points of diagnosis, that labor is begun; and if, upon 
making examination per vaginam, we find the os uteri dilated ever 
so little, and the membranes rendered tense during the pains, we 
may be quite sure that the parturient process has commenced. The 
application also of the hand to the abdomen discovers during each 
pain a hardness and rigidity of the uterine globe that give place 
to a flaccid and yielding softness during the absence of the pain. 
Such are signs of the true pains of labor. 

Touching or Examination. — If the patient's assent can be obtained, 
after the proper reasons for asking the privilege of making an exami- 
nation per vaginam have been laid before her, we should have two 
principal objects in view, while performing that operation: one of 
these is, to note the presentation, and the other, the position. 
There are other observations to be made at the same opportunity, such 
as the degree of softness or relaxation of the parts — their moisture or 
dryness — the state of the rectum, and the sensibility of the parts. 

Upon obtaining the patient's consent to the examination, she should 
be requested to lie on the bed upon her left side, with her hips near 
the foot of the bed, and the knees drawn upwards towards the abdo- 
men, a small pillow having been previously placed betwixt the knees. 
Except upon occasions of the greatest emergency, a third person 
should always be present, and the physician ought to refuse to 
perform the operation of Touching, except in the pre- 
sence of a third person, who ought to be some elderly indivi- 
dual, acting as the nurse for the occasion. 

Let the attendant provide a napkin, and a small quantity of poma- 
tum, lard, or other unctuous substance, and a basin of water for the 
hands. When a smart pain comes on, the left hand of the practitioner 
being pressed against the sacrum of the patient, outside of the bed- 
clothes, the fore-finger of the right hand, properly anointed with the 
lard, should be introduced into the vagina, nearest to, and pressing 
slowly upon its posterior commissure, taking care not to bruise or irri- 
tate the patient by any rough or hasty proceedings. If the point of the 



LABOR. 259 

finger be now carried along its posterior wall, towards the upper extre- 
mity of the vagina, the os uteri is felt, and its degree of dilatation ascer- 
tained. When the finger comes to the os uteri, if the pain still continues, 
let the greatest care be taken not to rupture the chorion or bag of waters, 
as it is called, especially in a first labor. These membranes are 
extremely tense during the pain, which forces them down through 
the opening of the womb, forming the segment of a sphere, of greater 
or less size, according to the greater or less degree of the dilatation : 
if they should be too rudely touched while in a state of tension, they 
might burst, and permit the liquor amnii to escape; an unfavorable 
event in the early stage of labor, which it both retards and renders 
more painful. There is no need for pressing against the bag of waters 
during the pain, because, by waiting until the pain subsides, the bag 
becomes relaxed, and can then be pushed back again w T ithin the 
mouth of the womb, so as to enable the finger to touch the head. For 
the most part, we only ascertain, in such an examination, the pre- 
sentation, and being satisfied with that, we wait until a great dilata- 
tion, or the discharge of the waters, allows us to discover the p o s i t i o n . 
During the operation of Touching, we also endeavor to learn the con- 
dition of the orifice of the womb, as to whether it is rigid, unyielding, 
or soft and dilatable ; whether it be thick and dry, or thin and moist, 
with an abundant discharge of glairy phlegm. We also ascertain if 
the os uteri is in a favorable position, that is, in the middle of the 
pelvis, w r here it ought to be; or on one side; or high up behind, to- 
wards the sacrum ; and we rectify its position, if need be, by changing 
the situation of the mother to her back, or to either side, according 
as we may judge most fitting to bring the mouth of the womb into its 
proper place. Thus, suppose the mouth of the womb inclined alto- 
gether to the right side of the pelvis, the patient being on her left 
side; let her turn on to her back, or quite over to her right side, and 
the axis of the womb will be brought more nearly to the middle line 
or axis of the pelvic canal. We are, also, in this operation, to form 
an opinion as to the probable resistance to be made by the vagina, 
perineum, and labia, so as to make up our prognosis, which it is best, 
however, to keep as a secret not to be divulged for the present. 

At length, the pains having opened the os uteri to the greatest ex- 
tent, (as in Fig. 71,) and driven down the bag or bladder of waters 
almost to the orifice, the membranes burst, and the fluid of the ovum 
escapes with a gush. As soon as practicable after the escape of the 
liquor amnii, the Touching should be repeated, and now there is little 



260 LABOR. 

difficulty in determining the position of the head, though it may often 
be ascertained through the unruptured membranes. 

In general, that side of the pelvis in which the head can be felt at 
the lowest level, is the one to which the vertex points — for the vertex 
already dips, in order to enter the bony canal. But if, upon feeling 
the scalp with a finger firmly pressed upon it, a suture is discovered, 
which, upon being traced, is found to meet with two other sutures, 
and no more, that point of meeting will be the posterior fontanel or 
vertex; and it will be in the first position if it be near the left aceta- 
bulum ; in the second position if it be found near the right acetabu- 
lum, and in the third position if it be directly behind the symphysis 
of the pubis. But if, instead of three sutures, there be four, with a large 
membranous or soft space betwixt their points of union, it will be the 
anterior fontanel; and if it be near the left acetabulum, the head will 
be in the fourth position; in the fifth if it be to the right aceta- 
bulum, and in the sixth if it be near the pubis. 

False Pains. — There are a sort of pains that afflict some women 
towards the end of pregnancy, which, however severe and unbear- 
able they may be, are nevertheless very justly denominated false 
pains, to be discriminated only by Touching. 

I have many times been kept out of my house all night in order to 
be near a patient supposed to be in labor; and having been refused 
the privilege of making the examination until morning, after so tardy 
an admission of my request, I have found an os uteri perfectly closed, 
and a still tubulated or cylindrical cervix: so that I have been obliged 
to announce not only that the patient was not in labor, but that she 
had not yet reached the full term of pregnancy by ten days or a 
fortnight. 

It is exceedingly vexatious thus to be baffled by the unreasonable 
backwardness of the patient to submit to an operation which she 
knows to be necessary and inevitable; but we shall, in all early 
stages of labor, except those where the water comes off at the very 
commencement, be liable to such disappointment and deception, 
until we verify our other inferences by the infallible test of Touching. 

The similarity of these false pains to the true pains of labor is very 
great; there is even to be felt the hardening of the abdomen: .but, if 
carefully appreciated, it will be found that the rigidity is occasioned by 
a contraction, not of the womb itself, but of the muscles of the belly, 
that are so constricted upon the uterine tumor as to make even the 
womb appear to be contracted ; whereas it is actually only compressed. 



LABOR. 261 

False pains, then, are essentially involuntary contractions of the abdo- 
minal muscles. They are, probably, of the nature of tenesmus, and 
are caused either by the ventral irritation produced by the distended 
womb, or else by intestinal irritation from sordes, flatus, acidity, rheu- 
matism, and other causes that would also suffice, in the non-gravid 
state, to bring on spasms of the abdominal muscles. The difference 
between those of the non-gravid and those of the gravid state is, that 
in the former they are paroxysmal, but in the latter they are regularly 
periodical; which latter character they acquire from some law of the 
uterine innervation that I am unable to explain. 

False pains are, likewise, common symptoms of rheumatism of the 
womb. This rheumatic disorder is far more common than has gene- 
rally been supposed ; and, when misunderstood, is the fruitful source 
of anxiety and doubt to the practitioner, besides of insufferable dis- 
tress which it occasions for the patient herself. 

Wigand, Geburt des Menschen, band. i. p. 82, says that although 
rheumatismus uteri is sometimes connected with rheumatic pains of 
other parts of the body, yet, for the most part, only the womb and 
organs of generation suffer on such occasions. The causes, he thinks, 
are to be found in the hyperaesthetic state of the gravid womb, its 
exposure to cold from its projecting condition, and carelessness as to 
Jress during pregnancy. 

The characteristic signs of the disorder in labors, consist, according 
:o Wigand, in a general painful sensibility of the womb to the touch, 
vvhich is attended with contractions of the organ that are painful alike 
at the beginning, middle, and end of the labor-pain. The pain of a 
contraction in the rheumatic womb differs thus from that of a healthy 
uterus. In the latter, a normal pain gives no distress during the first 
half of the contraction (Wehen Cyklus), for the pain of a labor-pain 
does not commence until the mass of the organ begins to exert its 
superior power by thrusting the presentation into the dilating cervix 
uteri and vagina. 

I have met with several instances of rheumatic gravid womb, where 
the woman was tormented with false pains for many days previous to 
the real attack of labor. In one delicate female, pregnant with her 
first child, there was daily pain in the womb for a month before the 
child was born ; and these pains had so far the external character- 
istics of labor, that the most experienced practitioner might be de- 
ceived by them, until he should clear up the diagnosis by the Touch. 
The Touch alone could convince him that the os uteri was not in the 
least concerned in the matter; the tubule or cylinder of the vaginal 



262 LABOR. 

cervix remaining as complete!}' undeployed as in the most perfect 
repose of the gestation. In all such instances, the globe of the womb 
is sore to the touch, and only the slight occasional condensations that 
occur in all wombs towards the close of pregnancy could be looked to 
as the sources of the patient's distress. It may well be conceived 
that a rheumatic uterus could not but be painful whenever its parts 
should be disturbed by the normal contractions of its muscular tissue. 

In certain examples of rheumatism of the uterus, I have found the 
patient with a sore belly, often finding herself in apparent labor and 
as often disappointed ; yet disclosing to the Touch a partially dilated 
os uteri for many days, yea, even for a whole month, before the veri- 
table attack of labor came on. 

Let the Student remember that when he shall be hereafter sum- 
moned again and again, to a false alarm, as it is called, for the same 
patient, he will probably have to treat a rheumatismus uteri. 

Let him bleed such patient; let him keep her in bed, covered rather 
too warmly than not enough so with bed-clothes ; let him give her 
some doses of Dover's powder, or anodyne enemata, at night; let her 
abdomen be bathed two or three times a day with equal parts of warm 
oil and laudanum, and let him see to it, that she entertain a soluble 
state of the bowels by means of gentle aperients, of which a pure pre- 
cipitated sulphur, with calcined magnesia, is the most to be desired. 

Case. — I advise the Student early to come to the resolution of being 
cautious in giving his diagnosis and prognosis of these doubtful cases 
of labor. I know that there belongs to professional men a disposition to 
pronounce at once. This, perhaps, arises from a false pride, which 
prompts them to seem to know all things at a glance, or by mere 
intuition. If the young beginner, being called to a supposed case of 
labor, should witness a very regular recurrence of pains in the belly, 
and should also place his hand on the abdomen of the woman during 
one of these pains, he might find it very hard, and be led to pro- 
nounce, "Yes, it is her labor." Let him never pronounce, let him 
never give an opinion until he knows upon what it is founded. For 
example, I was called in the month of July, 1841, to a lady having 
very regular pains, which she said were like those she had experienced 
in her two former labors. During one of these I held my hand on the 
abdomen, which became hard, and evidently so because the womb 
was contracting strongly. " How far are you advanced, madam, in 
your pregnancy?" " Seven months and one week, sir!" "In that 
case I ought, before making any prescription, to learn absolutely 



LABOR. 263 

whether the womb is opening or not; for if it be opening, then your 
labor is begun, and must proceed ; if not, then you ought to have some 
remedy to prevent it from beginning, lest your child should be born 
prematurely, and thereby lost, from its non-viability." Effectively, 
I found the os uteri open so much that I could introduce two fingers 
and touch the chorion, which was tense. The cervix yet retained a 
quarter of an inch of its tubular form. I said, "You are in premature 
labor; but, as there is not the least degree of vascular excitement, 
and no pain except this that you complain of, I shall give orders to 
send you a potion of laudanum, in hopes of arresting the case here." 
She went out to her full time, up to which date I was repeatedly called 
to give assistance in her supposed attacks of labor. But, when the 
labor came on in earnest, the relaxation of the cervix w T as already so 
great that she delivered herself in a very few minutes. I am sur- 
prised, when I reflect upon it, that the retentive power of the cervix 
and os uteri should have enabled her so long to keep the ovum within 
the womb. This was doubtless a specimen of disordered innervation 
of the womb, arising from a rheumatic principle acting on the mass 
of that organ. She had just come ashore from an East India ship, 
from Madras. 

Such cases as the above occur repeatedly in course of a consider- 
able practice. I have seen a patient with the os uteri as large as a 
dollar and with strong pains, cease to suffer, sit up, walk about, and 
even go out for days in succession, before the labor was resumed and 
terminated. 

The regular manner in which labor pains recur has long been 
the subject of curious speculation. I have not found any writer 
whose explanation of this periodicity satisfies me, and shall not repeat 
here for my reader the mere hypotheses which I reject myself. It is 
enough to state that the contractions increase in frequency and power 
in proportion as the uterus grows small, or approaches more nearly 
to the moment of excluding its gravid contents — a most singular phe- 
nomenon, which, of itself, is almost sufficient to refute all the existing 
hypotheses as to the anatomical arrangement and composition of the 
muscular texture of the organ. The observation, however, is per- 
fectly true. In the contraction of the muscles of locomotion or relaxa- 
tion we find that the greatest power of the organ is excited at a point 
midway between elongation and the greatest condensation. Thus 
the biceps acts with the greatest force w T hen the arm is bent to a right 
angle, and not when it has drawn the hand up to touch the clavicle, 
nor when the arm is fully extended; but in the case of the uterine 



264 LABOR. 

fibres, if we adopt the common theories, we must admit that the 
nearer the extremities of the muscular fibres are brought to each 
other, the stronger do they act. In the case of the uterine fibres, 
whatever be the cause of the first contractions, or whatever be that of 
the periodical return of them, both the forces, periodical and dynamic, 
seem to acquire strength by exertion. The weakest pains are those 
which are met with in women who have the womb enormously dis- 
tended with water, or with twins; the uterus, in such cases, seeming 
to be distended beyond the just limit, and to lose thereby its tonic or 
contractile force; a case similar to that which is observed in an over- 
distended bladder, w T hich, as is well known, refuses to act upon its 
contents; so that, even with the catheter introduced, it is sometimes 
necessary for the physician to aid the bladder by pressing his hand 
strongly upon the hypogastrium. 

The indisposition to energetic movement in a womb too greatly 
distended by an excessive quantity of liquor amnii, or by double preg- 
nancy, may for the most part be obviated by early rupturing the ovum, 
and allowing the waters to run off; but we cannot, even by this prac- 
tice, always remove a certain atony or apathy of the womb, which em- 
barrasses the labor very much ; nor prevent a troublesome hemorrhage 
after delivery, the consequence of that atony. The womb, like the 
bladder, when once over-strained by distension, is exceedingly prone 
to relax and fill, so as to become over distended again, because it is 
inert — atonic. 

In a labor pain, it does not happen that the whole muscular appara- 
tus of the womb enters into contraction at the same moment of time. 
The fundus may be the first to begin the contractile movement, or the 
muscular mass of the cervix may take the initiative in the action, 
which, extending slowly over the whole muscular tissue, engages it 
at length in one uniform and equable effort at condensation of the 
whole womb. 

The observation of this fact is due to the celebrated Wigand, already 
quoted, one of the most careful and intelligent investigators of the 
phenomena of parturition who has existed in any age or country. 

Since my attention was called to it, in his beautiful work, Die Ge~ 
hurt des Menschen, I have many times noticed, that the earliest evi- 
dences of movement, upon the recommencement of the pain in labor, 
was a gentle drawing together, constriction or contraction of the mouth 
of the womb. This motion I have discovered by the Touch, before 
the woman herself was made conscious of it; and I have said: "Now 
the pain is come," to which she replied in the negative, but soon cor- 



LABOR. 265 

reeled her speech; for, as I have said, when the contraction begins in 
the cervix, it overspreads or extends to the whole organ. 

The fundus, in other instances, is the first to exhibit manifestations 
of contractility. In this case, if the indicator finger be held in con- 
tact with the circle of the os uteri, so as, at the same time, to touch 
the bag of waters or head of the foetus, it will be found that the bag 
grows more tense and begins to descend ; or the head moves down- 
wards, being urged on by the contraction of the fundus, before the 
circle of the os is felt at all to harden or constringe itself. 

In a labor pain, the whole womb contracts. Let not the 
Student, then, imbibe the false notion that the cervix relaxes while the 
fundus and body contract. It is true that he will find, in a labor pain, 
that the contraction of the fundus commonly lasts longer than that of 
the cervix, and that the cervix becomes more dilated towards the latter 
half than in the first half of a pain, agreeably to Wigand's observation, 
ante. If a pain continues twenty seconds, and the woman is to be 
exhorted to bear down her pain, she ought not to begin to bear down, 
during the first ten seconds, but she should exert herself to improve 
the last ten seconds. The advantage of doing so has appeared to me 
very great, in numerous labors that I have superintended. 

In the matter of labor pains, it is worthy of remark that the tenor of 
them is uncertain, and the action often capricious. For example, the 
cervix may give way regularly and progressively to a certain point, 
where its dilatable disposition ceases, for a time. It is wrong to prog- 
nosticate of a matter so uncertain. A man founding his prognosis 
upon the uniform progress of the dilatation in a labor, may announce 
that the end is nigh — when the dilatability is only nigh to a certain 
point, where it is destined to stop for many hours. 

Near the end, when, by the contractions of the fundus and corpus 
uteri, the child's head has been forced partially into the vagina or 
quite through the os uteri, the tenesmus, or straining with the auxiliary 
or abdominal muscles, begins, and, as I have already mentioned, the 
whole womb, with its contents, is now pushed downwards. Under 
these circumstances, the circle of the os uteri first descends very low 
in the excavation, and its anterior lip may be felt, stretched behind and 
across the pubic arch, a little below its crown. There is no labor in 
which the anterior segment of the circle of the os uteri does not descend 
lower than the crown of the pubal arch in front; but as soon as the 
mouth of the womb is fully opened, and the head completely lodged 
in the vagina, the lips of the womb ascend, probably, quite to the top 
of the pelvis in front, and as high as the projection of the sacrum be- 



266 LABOR. 

hind — the os uteri encircling the throat of the foetus with a gentle or 
moderate contraction. At this stage of the labor, the fundus uteri 
approaches much nearer the os uteri — nearer by at least four inches, 
or four and a half, perhaps. 

When the head escapes from the vulva, the thorax of the child 
takes its place in the vagina, and at last, as the thorax emerges, the 
abdomen and lower extremities succeed it in that place, so that soon, 
nothing remains in the womb but the placenta and membranes, with 
a few ounces of blood and water. The fundus is now not more than 
five inches from the os uteri, instead of twelve inches, as it was at 
the beginning of labor. The womb is strongly contracted in the last 
expulsive throe ; and if the placenta were not detached even earlier 
than this, it could scarcely retain its connection with the uterine sur- 
face, now that its superficies is so greatly reduced in size. In fact, 
we do find, in a large majority of cases, that the placenta is pushed 
wholly or in part into the vagina, by the same pain that forced the abdo- 
men and breech of the child to take that situation ; or if it be not thrust 
quite out of the womb, it lies loose and detached within the cavity of 
that organ, and ready to be expelled upon the slightest renewal of 
contraction, or even by the voluntary expulsive effort of the abdominal 
or auxiliary muscles. Instances do occur, of a morbid adhesion of 
the placenta to the womb, in which it is not detached even for some 
time after the birth of the child ; and I think I have noticed that where 
the attachment exists at the anterior part of the cavity, it is least apt 
to be thrown ofFby the same pains that expel the child. The con- 
stringing movement at the fundus is greater than at the front or back 
of the womb ; hence, a placenta attached to the fundus is more 
likely to come off well, than one seated on another part of the cavity. 

Extrusion of the Placenta. — The separation of the placenta is 
commonly followed by an effusion of blood. This effusion is incon- 
siderable in proportion as the action that condenses the uterine tissue 
is more energetic and stable. It is supposed that nearly all, if not 
all, the blood that comes off, flows from what was the placental surface 
of the womb. Now, as the placenta is from fifteen to twenty inches in 
circumference, it will occupy a space equal to such a superficies, on the 
w T omb, before labor begins; but when the womb has contracted so as 
to be no bigger than two fists, the placental surface of it must at last, 
come to be not more than one and a half or two inches in diameter, 
so that the effusion from its vessels is greatly checked, and, in very 
tonic uteri, wholly suppressed for a time. If in any case the tonicity 



LABOR. 267 

ceases to exist, then the womb expands again more or less, and blood 
begins to flow. The womb becomes condensed by the muscular con- 
traction, for the muscular fibres are disseminated everywhere in the 
substance of the organ; but, inasmuch as there is a great deal of arte- 
rial, capillary, venous, absorbent, and cellular matter that serves to 
make up the sum of the uterine mass, these materials, which are 
not contractile, serve as an elastic resistance to the muscularity, and 
thus cause the organ to spring open again as soon as the muscles 
relax, or lose their tonicity. It is desirable, therefore, after delivery, 
to have a well contracted and tonic womb. 

The Child. — During the whole of this process of parturition, the 
child is quite passive : if alive, its body possesses a certain degree of 
firmness and solidity (wanting in the dead foetus) that enables the 
womb to force it downwards, and cause it to dilate the parts it is 
destined to pass through. It does not assist itself; as indeed it could 
not do, with its thighs and arms flexed upon the body, and the legs 
crossed perhaps upon the epigastrium, and pinioned by the coats of 
the womb, which press it together into a compact and passive mass. 

If the child be dead, and especially if it have been long dead, its 
tissues are less firm and resisting; its articulations are all loosened, and 
even the cranial sutures become relaxed; so that when the contractions 
of the womb act upon the foetus to expel it, the whole mass of it yields, 
to a certain extent, and is squeezed together by the pains. Under 
such circumstances, the parts to be dilated are opened much more 
slowly; for a portion of the power is expended or lost in pressing the 
soft and yielding mass of the child into some degree of solidity before 
it can be efficaciously impelled against the organs to be riven open. 
A child long dead, in a first labor, is often, therefore, a cause of trou- 
ble. It might almost be true to say, that in this sense, a living child 
helps itself in the labor, while a dead one does not. 

Outward Thrust of the Spinal Arch of the Child. — At the 
beginning of labor, the womb acts only upon the ovum en masse: 
compressing the membranes and their contents. The lower part of 
the chorion is pressed like a bag into the os tincse, and protrudes 
through it, and is often burst and the waters discharged, before the 
fundus of the womb comes to press firmly on the child's breech and 
push it downwards. But whenever the fundus uteri does begin to 
compel the child downwards, it can only do so by acting on the pelvic 
extremity of the spinal column. The cephalic or cervical extremity 



268 LABOR. 

of this column, of course resists the force, and the spine becomes 
more arched. It is as if one end of a bow were set up on the floor, 
and the hand resting on the upper end should press it directly down- 
wards in order to bend the bow. The outward thrust of the arch is in 
this case so great that the ends of the bow strive to retreat to the 
parallel of the centre of the piece. In the same manner the cervical 
end of the spinal arch, attached as it is to the condyles of the occipital 
bone, will naturally thrust backwards and thus raise the vertex and 
depress the chin; or I should rather say (as the head is downwards), 
it will depress the vertex and raise the chin, forcing it towards the 
infant's breast ; while the vertex, which is the occipital extremity of 
the occipito-mental diameter, descends, as the presenting part. 
This happens the more readily, as the child's head lies over the pelvic 
opening, which, so to speak, yawns to receive it. 

This bending of the neck, or carrying of the chin to the breast, is 
a most important act in the mechanism of a labor; it is called the 
flexion of the head; and when it takes place in due degree, it 
enables the head to descend into the pelvis with very little obstruction; 
for the other change, called the rotation of the head, does not take 
place well if this first step fails. The head of a child at term passes 
very easily into and through a well-formed pelvis, provided it present 
certain of its diameters only to the canal. Now the diameter extending 
from the child's chin to its vertex is 5.5 in many children; but the 
outlet of the pelvis is nowhere more than four and a half inches, at 
most. Of course, the child could not be born should it present such a 
diameter. Again, the diameter extending from the vertex to the space 
between the eyebrows, is fully 4.5, and often more than that; but from 
one ischial tuberosity to the other is but four inches, so that were this 
cephalic diameter of 4.5, to be parallel with this bis-ischiatic diameter 
of four inches, the head would stop ; it could not descend any farther. 
The vertical diameter of the head is, however, only 3.75, which is 
smaller than any one of the pelvic diameters ; so that no great ob- 
struction can, in any natural labor, be offered by the bones, provided 
the chin be, early in the process, borne strongly against the breast, so 
as to make the vertex descend, and cause a considerable dip of the 
horizontal diameter of the foetal cranium. 

Positions. — The promontory of the sacrum juts into the superior 
strait in such a manner as to turn any rounded body off, either to its 
right or left side, and accordingly, it rarely happens that either the 
forehead or the vertex can pass down immediately in front of the pro- 




LABOR. 269 

montory ; but, as there is a concavity on each side of it, the vertex, 
or the forehead, passes down in this concavity, which gives to the 
head an oblique direction, as to the opening, or plane of the superior 
strait. The cut shows how the intrusion of the promontorium into the 
outline of the superior strait, may 
serve as a guide to the forehead, com- Ig " ' 

pelling it to rest in the right, or in the 
left sacro-iliac space, as the case may 

be. The forehead, in a majority of \ mSSsxV ' I 

instances, goes to the right of the 
promontory, or in front of the right 
sacro-iliac symphysis, while the ver- 
tex descends below the brim, oppo- 
site to the left acetabulum ; not at a fixed point, but either nearer the 
front of the pelvis, or more posteriorly, as the case may be. Indeed, 
the child generally is found to bore with its head, so as to turn the 
vertex now forwards and now backwards, until at last it becomes 
fixed in one position, by getting under the arch of the pubis. So 
common is it to observe the child to descend with the vertex opposite 
to the left acetabulum, that that is taken or counted as the first posi- 
tion of a vertex presentation; and Baudelocque, whose authority on 
this subject is much followed in the United States, enumerates a 
second, third, fourth, fifth and sixth position, the enumeration or order 
being founded on the supposed relative frequency of the several sorts, 
as they are met with in practice. 

Thus the most frequent, according to Baudelocque, is the first posi- 
tion, in which the vertex is directed to the left acetabulum, and the 
forehead to the right sacro-iliac symphysis. 

Next in order is the second position, in which the vertex is to the 
right acetabulum, and the forehead to the left sacro-iliac symphysis. 

The third position is that in w T hich the vertex is behind the pubis 
and the forehead in front of the promontory. 

The fourth position is that where we find the vertex at the right 
sacro-iliac symphysis and the forehead towards the left acetabulum. 

The fifth position is that in which the vertex is at the left sacro-iliac 
symphysis, and the forehead towards the right acetabulum. 

And lastly, the sixth position, wherein the vertex is at the promon- 
tory and the forehead at the symphysis pubis. 

It is doubtless extremely convenient and proper to reduce all the 
possible modes of vertex presentations to a small, yet sufficiently 
comprehensive classification : but the reader, and especially the young 



270 LABOR. 

Student, should remember that all these classifications are human 
inventions. They are the proposita or the dogmata of different men ; 
and, in fact, it is possible for any presentable part of the head to pre- 
sent itself at any part of the brim. If he should, however, find any 
difficulty in remembering the order or application of these several 
positions, let him make use of such an arrangement as the following, 
which I place before him in this connection, rather than refer him back 
to an antecedent page. 

Beginning with the vertex at the left acetabulum, let him say, ver- 
tex left, then proceeding to the second position, in which the vertex 
is at the right acetabulum, let him say vertex right, and so on for the 
whole of the six positions as follows: 

Vertex left, vertex right, vertex front. Forehead left, forehead right, 
forehead front. 

If the vertex be at the left acetabulum, the forehead is of course at 
the right sacro-iliac symphysis; if it be at the right acetabulum, the 
forehead is at the left sacro-iliac junction, and vice versa; for all these 
six positions are vertex positions. So, if it be forehead left, the ver- 
tex is at the right sacro-iliac joint. If the forehead be to the right, 
the vertex is near the left sacro-iliac symphysis ; if the forehead be 
front, the vertex is towards the promontory. Hence I repeat, vertex 
left, vertex right, vertex front; forehead left, forehead right, forehead 
front. The first three are occipito-anterior positions, and the last 
three are occipito-posterior positions. 

I have ever found this enumeration the easiest one to remember, 
and as a real nomenclature of the positions, I prefer it to all others, 
and recommend it to the Student of Medicine. 

Madame Boivin, in her Memorial sur VArt des Accouchemens, gives 
us a table showing the relative frequency of these positions. 

In her practice, in 20,517 births, there were 19,584 vertex pre- 
sentations, of which there were of the 

1st position, 15,693 



2d 


u 


3,682 


3d 


a 


6 


4th 


a 


109 


5th 


a 


92 


6th 


a 


2 



Madame Lachapelle's practice in 22,243 births, showed that there 
were 20,698 vertex presentations, of which there were of the 



LABOR. 271 

1st position, 15,809 
2d " 4,659 

4th " 164 

5th " 66 

That distinguished Obstetrician, Dr. C. F. Nsegele, Professor of 
Midwifery at Heidelberg, asserts, that while the most ordinary position 
of the vertex presentation is that in which it is found nearest the left 
acetabulum, the one next in frequency is the fourth, or forehead left 
position, and he calls it therefore, the second, in his enumeration. Dr. 
Nsegele makes this enumeration of first and second positions at page 
114 of his Lehrbuch der Geburtshiilfe, fyc, and at sect. 264, p. 120, 
gives his views as to the very ordinary occurrence of fourth positions ; 
and at sect. 267, p. 122 — declares that, ceteris paribus, the forehead 
left positions are as favorable for the mother and child also, as the 
first or vertex — left positions, the vertex rotating spontaneously from 
the right sacro-iliac junction to the right acetabulum, and then to the 
pubal arch. 

In a conversation I had with this venerable and most honored pro- 
fessor at Heidelberg, in 1845, he gave me convincing proofs of the 
correctness of his opinions of this circumstance. 

Indeed, I kept a register of presentations a few years since, upon 
learning, through a publication of Dr. N.'s Mechanism of Labor, made 
by Dr. Edward Rigby, now of London, that the common view as to 
the greater frequency of the vertex right position, was erroneous. I am 
fully convinced, by my registry, and by the course of my clinical ex- 
perience ever since, that Prof. N. is quite correct in his statements, 
and I venture to assure the Medical Student, that while he shall surely 
meet with vertex left positions more frequently than any others, he 
shall as surely find the forehead-left positions next in point of fre- 
quency. 

This is a comfortable doctrine ; for, the tyro, who has studied in the 
books the so-called mechanism of the head in the pelvis, is very likely 
to be startled at the first case of forehead left presentation he shall 
meet with; but if he now learns that it is a natural position, and the 
one second in point of frequency, he will not suffer himself to be dis- 
turbed by the occurrence; particularly if he remembers Dr. Nsegele's 
assurances, as above expressed. Dr. N.'s words are: "Die geburten 
bei der zweiten shadellage gehen, unter ubrigens ganz gleichen um- 
standen, durchaus ohne grossere Schwierigkeit als die bei der ersten, 
vor sich, und es hat nicht den allermindesten Einfluss auf die Mutter 



272 LABOR. 

oder das Kind, ob der Kopf sie in der ersten oder in der zweiten Sha- 
dellage zur Geburt stellt." 

Dr. Edward Rigby, of London, who was Prof. Nsegele's pupil at 
Heidelberg, translated, some years since, as I stated, a small volume 
of his worthy teacher's, on the mechanism of labor. At p. 36, Dr. X. 
informs us, that, according to his observations during many years, made 
with the greatest possible care and attention, the fourth position, that in 
which the occiput is near the right sacro-iliac symphysis, is, after the 
first, far the most frequent in occurrence of all the head presentations; 
whereas, he thinks the second position of the vertex occurs very 
rarely. Out of one hundred labors where the head presented, there 
were twenty-nine cases of the fourth position ; and out of another 
series of thirty-six labors there were twenty-two of the first, and eleven 
of the fourth position. The result of his inquiries shows that the 
fourth is to the first position in frequency, as one is to two and a half. 

I am glad to be able to confirm Dr. N.'s statement so far as to say, 
that I am of opinion, from my own experience and observation, that 
the fourth position is far more frequently met with, in my own prac- 
tice, than any other except the first. The reader has already seen in 
the table, that in Madame Boivin's records the relative frequency was 
15,693 of the first, 3,682 of the second, and only 109 of the fourth. 
I am sure that the statistical review will not be borne out by the 
experience of the reader of our Midwifery Library. Prof. Simpson 
agrees with Dr. N.'s views. 

Mechanism. — Let the head enter the pelvis obliquely, the vertex 
being in the first, or vertex left position — it is not to be understood 
that the dip of the horizontal diameter of the head will carry the 
posterior fontanel into the centre of the pelvic canal: on the contrary, 
such a dip would be too great — and the vertex, or posterior fontanel, 
glides down along the ischium, repelled by that bone, and directed by 
its inclined plane inwards and forwards ; so that it describes a spiral 
line in its descent, and the vertex, which on entering the upper strait 
was directed to the left, is, without any change of posture of the 
child's body, turned near a quarter or a sixth of a circle, to bring it 
under the arch of the pubis, beneath which it extends itself again 
after recovering from its first flexion, so as to allow the crown of the 
head, the forehead, the face, and last of all the chin, to roll out, in 
succession, from the floor of the vagina and edge of the perineum. 
These three mutations are the most important in the mechanism of 
labor: first, the flexion; second, the rotation; and third, the extension 



LABOR. 273 

of the head. The regular succession of these several states is neces- 
sary to an easy natural labor; and the principal business of the medi- 
cal attendant, in such labors, is to see to it that they occur in due 
order and time. 

I am reminded here of the necessity there is to warn the Student 
to stop a moment, and consider what is really the presenting part in a 
first or vertex-left position. He should reflect that the fontanel, which 
is directed towards the left acetabulum, is a good ways off from the 
ostium vaginae towards the left — and that in fact, the part that he 
Touches in his Examination is the right parietal bone, whose 
parietal protuberance meets the point of the finger introduced for the 
exploration or diagnosis. To reach the vertex, therefore, he must 
carry the palp of the finger upwards and outwards, and backwards 
towards the left acetabular region, where it will come in contact with 
the triangular or occipital fontanel. In second positions or vertex- 
right positions it is the left parietal boss that presents and so on as to 
the rest of the positions. The vertex, therefore, is not truly the pre- 
senting point, in vertex labors. 

As to any person's being able to explain the mechanism of the 
pelvis, or its operation in parturition, without the aid of the subject, 
either recent or dried, I hold it to be an impossibility. Let the stu- 
dent, therefore, who wishes to comprehend this matter, which involves 
probably the most important information that he will have occasion 
for in obstetric practice — let him take a dried pelvis and a foetal 
cranium, each w T ell and naturally proportioned to the other — let him 
plunge the cranium into the excavation, holding it in the first position, 
but without flexion ; he will find that it cannot descend very far, on 
account of the rapid approach of the inclined planes of the ischia 
below. But if he now turns the vertex somewhat downwards, or brings 
the chin upwards, it will descend a little farther. As he presses it 
downwards, the inclined plane of the left ischium tends to repel 
and deflect it towards the pubic arch, in which direction no great 
bony resistance is offered. If it glance upon the obturator membrane, 
and indent it, the resiliency of that tissue is sufficent to repel it still 
more, and still more to deflect it towards the front ; in fact, it easily 
takes a pivot or rotatory movement, which is greatly enhanced or pro- 
moted by the structure of the back and lateral parts of the pelvic 
excavation, which are so inclined as to likewise repel and deflect the 
forehead, backwards, and cause it to fall into the hollow of the sac- 
rum. Let this experiment be tried both with the dip or flexion, and 
without it, and it will be seen that in the first case the rotation is 
18 



274 LABOR. 

almost spontaneous, and in the last very difficult, if not impossible, 
without powerful extrinsic aid. 

The rotation being completed, the vertex is found jutting forth 
under the arch of the pubis : it emerges more and more completely until 
the occiput, or the upper part of the nucha becomes pressed against the 
crown of the arch, when the further progress of this part ceases — it 
becomes a fixed point, or it is an axis, on which the head, as before 
said, turns or rolls out from the orifice of the vagina, at the close of 
which evolution the extension of the head is complete. 

After the head is born, the face turns again to the side of the pelvis, 
towards which it was directed at the beginning of labor, or before the 
rotation began; and that is called its act of restitution. If the 
vertex was left, when within the pelvis, it seeks the left when driven 
out of the excavation. 

While the head is undergoing these mutations, the shoulders of the 
child are entering the basin. In the first position, the vertex is to the 
left acetabulum, and the right shoulder to the right acetabulum, while 
the left one is to the left sacro-iliac junction. As the shoulders 
descend, the right one rotates towards the arch of the pubis, and the 
other falls backwards into the hollow of the sacrum ; the thorax is now 
plunged deep into the excavation, where its farther progress is arrested 
by the floor of the pelvis. A renewal of the uterine effort forces the 
left shoulder to glide off from the apex of the sacrum and coccyx, and 
displace the perineum, which it thrusts backwards, out of its way, 
until the shoulder is born. The edge of the perineum is now retired 
so far backwards as to allow the right shoulder to disengage itself 
from under the crown of the pubic arch; and the body of the child is 
immediately afterwards expelled with great violence, occasioned by 
the irresistible tenesmus the woman experiences in this stage ; and 
which compels her to bear down with her whole energy. Sometimes 
the shoulder nearest the pubis is first expelled; generally, the other is 
the first to be born. 

A repose of eight or ten minutes follows the birth of the child, and 
a slight pain, or a voluntary bearing down, expels the placenta and 
membranes, as before said. 

The almost supernatural exertions and struggles of the woman, as 
well as the painful sensations she experiences, and the novel impres- 
sions made upon her nervous system by the successive stages and 
occurrences of parturition, have brought about a violent excitement of 
the nervous and circulatory systems of the economy; the former of 
which is resolved by cries of joy, by tears, and by the delightful sense 



LABOR. 275 

of security, of triumph, and finished toil, and by that gushing tender- 
ness which a mother feels for her new-born and helpless progeny. The 
latter rapidly abates, under the greater or less abundant effusion of 
blood, and the abstraction of the stimulus of exertion, pain and dismay. 
The flood of perspiration gradually subsides, and a short sleep, the best 
restorative, soon permits the patient to feel "comfortable," a phrase 
peculiarly adapted to the case of a puerperal woman. A review of the 
whole of the phenomena, both physiological and psychological, that are 
evolved during the progress of a case of labor, presents perhaps the 
most perfect example of the state of hysteria that can be anywhere 
observed. I shall not devote these pages to a comparison of them 
with those of an hysterical paroxysm, but merely refer the reader to 
his clinical observation, whether past or future, for a confirmation of 
this view of the case. Indeed, the whole matter of a labor is ipso 
facto, a matter depending merely on a status or modality of the womb, 
and its influences, and sympathies. It therefore is a pure specimen 
of the local action and constitutional influence displayed by the child- 
bearing organs, and the whole of what Wigand calls the generation- 
sphere. 

The lochia, for such is the denomination of the bloody discharge 
that follows, flow in such abundance as to require five or ten nap- 
kins to imbibe the blood effused during the first twenty-four hours; 
after which they decrease in quantity, and grow pale, until by the 
tenth or fifteenth day, many women have none but a whitish discharge, 
which also ceases between the twentieth and thirtieth day. 

On the day after delivery, the globe of the uterus appears to be 
larger than it was immediately after the discharge of the placenta. 
It can generally be felt, in the hypogastrium, during from six to ten 
days ; after which it retreats into the recesses of the pelvis, diminishing 
daily in size, until, by the end of the month, it is nearly as small as 
before it was gravid. 

Such is the history of Labor, in general terms, which, though it 
may perhaps afford a pretty good coup d'ceil of the phenomena by 
which it is characterized, is not sufficiently in detail for the purposes 
of this work; on which account I shall proceed to treat of other par- 
ticulars in the ensuing pages. 

In general as soon as the signs of respiratory life are fully estab- 
lished in the child, it is severed by the attendant, who divides the 
navel string after having secured it with one or with two ligatures, 
and puts an end, by this severance, to all connection with its mother. 

As to the child, it comes, in a good labor, healthy and vigorous 



276 LABOR. 

into the world. The loud sounds of its vagitus, its cries, pervade the 
apartment and carry consolation and even transport to the bosom of 
the fatigued, exhausted, and terrified parent. "Ah, mio corazon! 
Mio carissimo, querido corazon," said a Spanish lady, from the midst 
of her pangs, as soon as the head of her offspring became free, and 
before the shoulders were born — for she heard its vagitus uterinus — - 
and her heart went forth with passionate expressions of love, to greet 
it even before it was completely ushered into the world. 

As a physician, who has passed a life among those who were in 
pain, in peril, and in fear of imminent death, I must have been 
witness to many scenes of human emotion — but of all the expressions 
of love, made manifest in voice and in speech, that I have ever wit- 
nessed, the most intense, the most rapturous and holy, have been the 
thoughts that breathed and words that burned as they vehemently 
issued from the lips of a young mother, whose body had just escaped 
from the fell sufferings of those who, in sorrow travail in child-birth, 
according to the primal woe pronounced against her sex. 

The child being born, it remains that the secundines, consisting of 
the placenta and membranes, shall be expelled from the uterine cavity. 
The same kind of power that was used to force the child into the 
world is required for the delivery of the after-birth. 

I believe that the after-birth comes off in about ten minutes. There 
are many labors in which the placenta is chased out of the womb 
into the vagina by the same pain that pushes the child forth. But, 
in general, this is not the case, the placenta being only loosened and 
detached, in whole or in part, and left lying crushed up into a sort of 
ball by the contraction of the womb upon it. 

After a repose of some ten minutes, it may be, and it is an indif- 
ferent matter, twenty minutes, the contractile power of the uterus is 
again in activity. This excites the tenesmus, as before, and the 
woman, bearing down, coincidently with the uterine contraction, 
pushes forth the after-birth, generally accompanied with coagula, and 
a quantity of fluid blood. The pregnancy is thus brought to its close. 

Lochia. — After the expulsion of the entire product of the concep- 
tion, the patulous orifices of vessels, left exposed by the separation of 
the placenta, freely discharge several ounces of blood. This dis- 
charge is called lochia. As the cavity of the womb is not obliterated 
by the conclusion of the labor, it must happen that the blood effused 
within its capacity shall coagulate, and that the patient shall dis- 
charge from time to time a utero-morphous-clot, as large as an egg, 



LABOR. 277 

or as large, sometimes, as a man's fist. As the organ grows smaller 
and smaller, these coagula become less and less; the flow assuming 
more and more the appearance of the menstrua. In the course of a 
fortnight in some, of a month, in others, the last traces of uterine ex- 
cretion dependent on the late pregnancy have disappeared, and the 
woman is restored to the Jewish estate of cleanness. 

The lawgiver of that ancient race pronounced that a woman could 
not be clean until the fortieth day. But our Christian women gene- 
rally deem a month sufficient for the whole process of the uterine pur- 
gation. 

As to the lochia, let the Student learn that when the milk begins to 
be abundantly secreted, which is on the third day, or about seventy- 
two hours after the close of the labor, the mammary molimen serves 
to check the determination to the womb ; and consequently to lessen 
the amount of the lochia — which, however, becomes again abundant 
on the fifth day. Can it be that the opened orifices of the uterine ves- 
sels, from which the lochia are discharged, shall return to their nor- 
mal, non-gravid condition, without the intervention of a state fit to 
be called phlebitis? Such is the proposition of an able French writer. 

Having now given a plain account of what happens in an ordinary 
labor, I shall in the next page proceed to give directions for the 
Conduct of a Labor. I cannot, in doing so, avoid some iteration, 
nor shall I apologize further for so doing, since, without repetitions, I 
cannot possibly maintain the even tenor of the story, for, though Ob- 
stetrics is a Science, it is made up of a vast number of unconnected 
items. 



278 CONDUCT OF A LABOR. 



CHAPTER X. 



CONDUCT OF A LABOR. 



The conduct of a labor comprises the whole management of a 
parturient patient, from the first begining of her pains, until the com- 
plete exclusion of the secundines ; and it ought also to include all 
that is done for the security of the mother and the child, during the 
period immediately ensuing the birth. As labors are extremely 
various in their characters, as to duration, pain, facility or difficulty, 
the title at the head of this chapter is a comprehensive one, and fruitful 
of topics which, if properly handled, could not fail to prove interesting 
and instructive to whatsoever reader might desire, under such a head, 
to seek for useful, and indeed I might say, indispensable information. 
The conduct of a labor might refer to any, and so to all possible 
events in Midwifery; for Midwifery, after all, is but the conduc t of 
labors. 

Any person meriting the name of obstetrician may be supposed 
competent to the conduct of a natural labor, where the series of 
phenomena proceeds with rapidity, and in a perfectly natural order 
of succession and duration, provided he will remember the oft 
repeated adage, "a meddlesome midwifery is bad;" and be therefore 
willing to abstain from impertinent interferences. A kindly Provi- 
dence has so ordered this painful office of parturition,, that the ac- 
coucheur, in most cases, hath really little to do except to receive and 
protect the child, and attend to the delivery of the after-birth ; 
extending his care to the disposal of both the mother and her offspring 
for the first few hours after the termination of the labor. To show 
w T hat the proportional number of unassisted or natural labors is, to 
those that require the aid of science or skill, I may state that out of 
twenty thousand five hundred and seventy children born at the 
Hospital de la Maternite, for the time under the care of Madame 
Boivin, only three hundred and thirty-four required to be assisted; 
leaving twenty thousand one hundred and eighty-three children that 



CONDUCT OF A LABOR. 



279 



came into the world by the natural powers dedicated to the office of 
parturition. An idea of the time required for the completion of the 
process of child-birth, may be gained from the following table taken 
from Dr. Churchill's Theory and Practice of Midwifery, 1846. 





o 


"3 • 

QJ CO 




m 


ro 


■<# 


Authors. 


►2 ■ 


rt 3 

a o 


3 
o 


3 
O 


3 
O 


> 3 




So 


E so 


08 


CO 




s ° 




o 
H 


Hf' 


a 


a 


a 


<1 


Dr. Merriman 


500 


206 


398 


442 


450 




Dr. Collins 


15,850 


13,012 


15,084 


15,346 


15,586 


264 


Dr. Maunsell . 


839 


347 


647 


734 


793 


36 


Dr. Beatty . . 


1182 


577 


958 




1114 


69 


Dr. Churchill . 


1285 


366 


760 


, 


1119 


166 


Dr. Granville . 


640 


• • 


515 


above 12 hours 


104 



Upon referring to Dr. Collins' work, p. 22, it will be seen that of 
the 15,850 cases observed, 7,050, nearly one-half, were delivered in 
two hours, and that 11,257 were delivered in four hours of labor, 
which is nearly three-fourths for the first four hours. 

Cautions. — Although it will appear from the foregoing statements 
that women generally are found capable of helping themselves, yet 
every labor is not a natural one, nor is every natural one an easy one ; 
and, where the deviation from the normal character of the phenomena 
is at all considerable, much reflection and prudence are required in 
order to prevent a natural labor from becoming laborious, difficult, or 
actually preternatural. Were it so, that all the cases of parturition 
should end favorably, and pass easily through their several stages, there 
would, certainly, be no occasion for medical interference, and we 
might lay down our vocation and take up a less disagreeable one. 
But the facts happen not so : hence, when a labor is protracted 
through many successive hours of apparently fruitless distress, the 
sufferer loudly claims that something should be done for her relief, 
which compels the medical attendant to employ such arguments and 
exhortations as may serve to reassure and compose her, or else adopt 
some real or pretended measures for relief, or for accelerating the 
birth. In the " Woman's Booke" the venerable Rainald says: "Also 
the Mydwyfe muste enstruct and comfort the partie, not onlye refresh- 
ing her with good meete and drinke, but alsoe with sweete wordes, 
gevying her goode hope of a speedefull deliveraunce, encouraging and 
enstomakyngher to pacience and tolleraunce, byddyingher to holde in 
breath so muche as she may, also strekyng genttily with her handes 



280 CONDUCT OF A LABOR. 

her belly above the Navell, for that helpeth to depresse the byrth 
downewarde." Fol. XL 

That practitioner confers a real benefit on his patient, who thus, by 
kindness, by a proper degree of candor, or the evident possession of 
confidence in his own knowledge or skill, either convinces the patient 
that the time is not at hand for intervention, or that, when the time 
shall arrive, all the needful judgment and dexterity will be employed 
for her security. A woman may utterly fail of all her courage and 
firmness, and so, by falling into a despairing or fretful humor, 
greatly retard and embarrass the parturient processes, to that extent, 
indeed, as to render some manual operation necessary, merely be- 
cause she has lost faith and trust in her attendant; which irritates 
her mind so as to act most disastrously on the physical functions : 
whereas, she shall recover a great, and indeed a sufficient degree of 
power, immediately upon the appearance of some other person, either 
celebrated for his professional abilities, or exhibiting in countenance 
and manner, the evidences of confidence in himself and in the re- 
sources of his Art. This observation, which is of the greatest truth 
and importance, is to be found in that admirable volume, the London 
Practice of Midwifery, which is supposed to present a summary of 
the lectures of Dr. Clarke of London. The young practitioner, who 
sometimes permits his own disappointment to affect in any degree, his 
remarks or his gestures, exerts a very injurious influence upon his 
patient. He ought under all circumstances to retain a perfect com- 
mand over his feelings; and, above all, to be in full possession of the 
most accurate theoretic knowledge at least, of the processes about to 
be perfected, and of the measures that are indicated in their several 
stages, whether they occur in the natural order and manner, or whether 
anything arise to interfere with or obstruct them. Such a practitioner 
will rarely lose the confidence of his patient, no matter how severe 
or protracted her sufferings may be. He will support her spirits and 
hopes with his steady and confident assurances of relief in due time, 
and thus prevent the mischief that ensues where the mind, distracted 
with pain, fatigue and dismal fears, carries disorder into all the func- 
tions of the body. Nothing conduces more commonly to the production 
of the very uncomfortable state of things now alluded to, than the 
making of rash promises or prognostics. No one can know be- 
forehand when a labor shall be terminated. If the first 
stages proceed ever so favorably, the latter may give the greatest 
possible trouble ; and any failure of a prognostic cannot but diminish 
the woman's reliance upon the ability of her attendant. No good 



CONDUCT OF A LABOR. 281 

practitioner makes them. Let the student of Midwifery, therefore, 
early resolve to avoid all the difficulties which arise from such great 
imprudence. 

It is true that the adept practitioner can sometimes make shrewd 
guesses as to the hour of deliverance — but he who sometimes gains a 
small credit for his success will find that he is a loser, in the main, upon 
the prognostications he may have made. Some very good grounds of 
prognosis he may take upon the fashion or form of the woman's body, 
as I have shown from Wigand at page 41 of this volume. He ought to 
learn something of her stature and shape — and it is proper for him to 
inquire as to any obliquity, any over distension, any deviation that may 
exist — and this he can do without offending the delicacy of the patient, 
who will rarely refuse to rise from her seat and stand up before him, 
that he may know if all is right as far as can be deemed by external 
palpation. If she be lying on the back, it is not at all difficult even to 
make but the diagnosis of the presentation, either by feeling the orbi- 
cular head at the fundus or cervix, or by auscultation of the abdomen. 
If he should find the foetal heart nearer to the fundus than to the cer- 
vix, he will know that the case is one in which the pelvic extremity 
presents. I have repeatedly ascertained, by touching the belly, during 
the absence of the pains, that I was to treat a breech case — and have 
made all my arrangements accordingly. 

Cautions as to the Circulation. — Few women go through 
labor without a very great acceleration of the pulse, and increase of 
its force and volume. This excitement is sometimes attended with 
the development of nervous symptoms, to such a degree as to require 
measures for its diminution. When carried to a certain extent, an 
increased activity of the circulation is very advantageous. It develops 
in the nervous system, both cerebral and ganglionic, a vast increase 
of energy, which is acknowledged and responded to by every part of 
the constitution, particularly the circulatory system ; and it serves to 
hasten the arrival of the happy moment of release, by augmenting the 
expulsive energies of the womb; to the vigorous and regular contrac- 
tions of which, a somewhat elevated state of the vital forces seems 
requisite in almost all cases. It should not be interfered with, then, 
except under peculiar circumstances : as, for instance, where it occa- 
sions headache, mental excitement verging towards delirium, or 
tremors, and irregular action of the muscles, carried to an unsafe 
extent. The excess of excitement ou^ht to be removed in such 
cases, in order to prevent it from passing into debility and exhaus- 



282 CONDUCT OF A LABOR. 

tion, the constant results of a great excess of it; and more especially, 
to obviate the danger of convulsions, apoplexy, and other accidents to 
which the female constitution is obnoxious under violent excitements 
or efforts. I have in a great many instances observed, that the pains 
have fallen, or become irregular and spasmodic, in consequence of 
this constitutional irritation, and that they have recovered their vigor 
and regularity by removing the excess of bed-clothes, bathing the 
hands, face and throat with cool water, and by the exhibition of 
cooling drinks, together with free ventilation of the apartment. Great 
comfort and even renewal of strength, hope and courage, commonly 
follow a change in the outward circumstances of the patient, as to her 
bed and other things relative to her labor. Thus a woman who may 
have been lying for seven or eight hours upon the same spot, comes 
at last to sink into a sort of pit made by the weight of her hips. 
The continued escape of fluids, as urine, liquor amnii, blood and 
serum, which are all heated by the heat of her own body, is frequently 
found to wet her up as far as the shoulder blades ; and she remains 
pinioned as it were to the spot, aching in every limb, and imploring 
death, which she really expects. Such a person should, as a mere 
office of humanity, be taken up, cleansed from head to foot, and 
replaced upon a bed made up with clean bed-clothes. In cases where 
these simple cares would not suffice, I have scarcely failed to re-estab- 
lish the regular course of events by taking blood from the arm. 

Notwithstanding that most women have a very greatly increased fre- 
quency and force of the pulse, during the more active stages of labor, 
it is not universally the case ; some females passing through the whole 
process without any change whatever in the rate of the circulation. 

Cases. — The following case was under my care on the 9th of Feb- 
ruary, 1828. Mrs. B., aged twenty-five years, in labor with her first 
child, was attacked with the pains at seven o'clock A. 2\I., and was 
delivered at twelve o'clock of a healthy female infant. The whole 
amount of blood discharged at the separation of the ovum did not 
exceed three ounces. The pulse was very slow throughout the labor, 
not exceeding sixty-five pulsations per minute, even during the most 
violent expulsive pains. Some time after the complete expulsion of 
the secundines, the os uteri was two inches in diameter, and as hard 
and smooth as a ring of ivory. November 3, 1840, I attended Mrs. 
W. C. L., aged twenty-two years, in labor with her first child. The 
pulse during the whole process never rose above seventy-two, and 
soon after the birth of the child fell down to sixty-five beats per 



CONDUCT OF A LABOR. 283 

minute. The labor commenced at two o'clock A. M., and terminated 
at five o'clock P. M. The pains, even the great ones, were but a few 
minutes apart, so that I have rarely witnessed a more tedious one, 
notwithstanding many have fallen under my notice which were much 
more protracted. 

I could cite many cases from my practice in which the pulse was 
quite unaffected throughout the whole process of parturition. 

Professor Dewees has been justly celebrated for the boldness and 
good judgment with which he has resorted to venesection, in some 
cases of labor. The quantity drawn by him, in instances which he has 
reported, although, doubtless, fully demanded by the exigencies at the 
time, and justified by the results, may, nevertheless, have induced some 
persons of lesser powers of discrimination, unnecessarily to resort to a 
similar mode and extent of depletion; hence, it is not uncommon to 
hear of very large bleedings, of thirty or forty ounces at a time, during 
labor. I must aver, that I think such very large abstractions of blood 
not often necessary, and would, therefore, take this opportunity to 
warn the reader to discriminate carefully, in making up his judgment 
concerning the quantity to be drawn in each particular case. For 
example, where the woman has become too much excited as to her 
circulation, in the manner above pointed out, I have no idea that it is 
necessary to draw away a great quantity of blood : let him not bleed, 
then, until, to use a very common phrase, the pulse is soft. He does 
not want a soft pulse. In labor, or at least in the violent stages of 
labor, the pulse ought to be full, vigorous, and somewhat accelerated. 
If he bleeds till the pulse becomes soft, he will substitute for a state of 
excitement and excessive power, one of debility and lowness, quite as 
much to be deprecated. 

The purpose of venesection, in the instances I at present propose, 
is to take off the strain of the blood-vessels — to mitigate the general 
stimulation which ensues upon too rapid a revolution of the blood. I 
therefore think that it is better, for the most part, to limit our bleed- 
ings, for these general purposes, to something under, rather than 
beyond sixteen ounces. But on the other hand, where symptoms, 
strongly threatening, of apoplexy, convulsions, pulmonary hemorrhage, 
inflammation, &c, make their appearance, the lancet should be used 
in the most fearless manner. The same is true of those cases where 
a great relaxation of the tone of the tissues is required for some special 
and pressing object, such as the relaxation of a strictured vagina, or 
a very rigid uterus, the removal of a violent congestive or inflamma- 
tory accumulation of blood in the brain. 5 &c. &c. 



284 CONDUCT OF A LABOB. 

Actus. — It is difficult to conceive of an individual who, when un- 
der high excitement, whether from fever or other causes, doth not 
experience a considerable diminution of that excitement, upon the 
operation of an aperient or cathartic medicine. 

The facility and promptitude with which the alvine discharge can 
be effected by means of enemata, renders a resort to them of very 
common occurrence: and, in fact, where only a slight reduction of 
excitement is wanted, they answer the end proposed very fully ; yet 
a dose of some neutral salt, of magnesia, or castor oil, may be bene- 
ficially administered, in instances where there is a promise of suffi- 
cient time for the alvine operation to take place before the delivery of 
the child. Aperient doses are the more evidently indicated, in labor, 
because it cannot be doubted that the constitutional disorder brought 
on by the pain and fatigue of labor, must, in some measure, extend 
to the digestive organs : nothing is more common than to meet wi:h 
parturient patients who vomit very much ; while water-brash, heart- 
burn, and sour eructations are also exceedingly common, and often 
quite distressing. 

As to the exhibition of purgative medicines to women in labor, 
it ought to be understood that in the selection of the article, care 
should be taken to provide one not likely to operate with violence ; 
which would be very objectionable, both as to the trouble it might give 
during the parturient process, and to the inconvenience experienced by 
alvine operations occurring soon after the birth of the child. For my 
own part, I prefer, in general, that a patient should not have a dejec- 
tion until the third day. Still I very commonly advise the exhibition 
of a dose of castor oil, in cases where I have to fear a long and reluctant 
dilatation of the cervix. I administer the drug in such cases, because 
I stem to have observed that the operation of it tends to subduct the 
power of the cervix and os uteri, or that it relaxes the sphinctorian 
force of the retentive fibres of the uterus, as it does that of the sphinc- 
ter-ani muscles. It excites also the expulsive faculty of the womb, as 
it does that of the colon and rectum, and abdominal muscles. 

Case. — This day, September 2d. 1848, I found an os uteri not big- 
ger than a swan quill, though the waters had gone off full fourteen 
hours, and the woman had had sharp pains for eight hours. I gave 
her a tablespoonful of oil, and in three hours the child's head had 
passed through the dilated os into the vagina. 

The foregoing remarks tend to show not only that medicines of an 
aperient kind are frequently indicated in obstinate and protracted 



CONDUCT OF A LABOR. 285 

labors, but they also show that great care is required as to the exhi- 
bition of food to such patients. Some food is wanted, particularly for 
those whose pains are of the lingering kind, and allow the process to 
remain unfinished for many hours. For the most part, tea, bread, or 
gruel, sago, &c, are found to suit the patient best. The best drinks 
are gum-water, toast-water, lemonade, cold water, and such articles 
as these ; the object here being to sustain the system, by means of 
nutriment, while under severe effort, at the same time that we care- 
fully avoid calling that effort in the direction of the digestive organs 
by overtasking them. The whole powers of the economy should, 
therefore, be husbanded and preserved, as much as possible, in their 
normal condition, in order that they may be directed and determined 
towards the womb and its auxiliary organs. In the case of a very 
slow labor, which should be unattended with constitutional symptoms, 
or any evidences of gastric disorder, a light broth, or even some small 
portions of very digestible meat, might, upon due reflection, be allowed 
to the patient. 

Decubitus. — The attitude of the patient exercises, in many circum- 
stances, a notable influence on the progress of labor. It is the almost 
universal custom, in this country and in England, to direct the woman 
to lie upon her left side, with the knees drawn up ; a posture which is 
highly convenient to the practitioner, and productive of the least possible 
exposure of the woman's person. But where the labor proceeds slowly, 
the heat and the pressure occasioned by lying still, under such circum- 
stances, become highly injurious. The woman ought, therefore, to be 
directed to turn on her back, or even on to the opposite side, or to rise 
and sit in an easy chair, from time to time. I do not recommend that 
she should be too much urged upon this point ; but I remark, that the 
influence of custom is so great, that a proposition to turn on the back 
is not unfrequently received here, with something like astonishment 
and aversion by the by-standers, who seem to regard that attitude as, 
at the least, one of indelicacy. Hence, it is proper to assign reasons 
for the request. 

In cases where the retardation arises from an improper direction of 
the expulsive forces, it is of the highest importance to direct the 
patient as to her attitude. For example, if a lateral segment of the 
os uteri can be felt towards the middle of the pelvis, and the other one 
is either out of reach of the finger, or very high up on the side of the 
ischium, it will be found that the fundus uteri is directed to one side 
of the abdomen, giving more or less obliquity to the long axis of the 



286 CONDUCT OF A LABOR. 

womb, and of course an oblique line of direction to its forces, which 
are decomposed, or partially nullified thereby. 

Case. — On Sunday, November 30th, 1828, I was sent for to visit 
Mrs. C, whom I found lying upon her right side. The pains seemed 
so expulsive, that when I arrived, I expected to receive the child 
immediately, for she bore down like one in the last throes of labor. 
I requested her to turn upon the left side, informing her that that posi- 
tion was the most convenient for me. She did so. The pains now 
became inefficient, and partook, in appearance, of the character of 
the grinding pains. I found that the uterus had obliqued far down to 
the left side, as soon as she turned over, which interfered with the due 
exercise of its power. She was again placed on the right side, which 
brought the womb into its proper line of direction, and the labor ended, 
after three or four pains. The same consequences follow from an 
anterior obliquity of the axis of the uterus ; but, in this case, the ante- 
rior segment, or lip of the womb, seems to hold the head as in a sling or 
pouch; the anterior edge of the orifice being stretched across the head, 
quite towards the middle of the pelvis ; whereas the posterior edge of 
the circle either cannot be felt at all, or is felt high up towards the 
promontory of the sacrum. It is evident, that in such a state of 
things, a good deal of power must be lost in pushing away the ante- 
rior part of the cervix, which should be preserved, or more usefully 
employed in other efforts. "We are advised, in order to remove the 
difficulty, to draw the os uteri forwards towards the symphysis, and 
retain it there by the fingers; but there are in many cases, a rudeness 
and violence in this plan, which will be easily understood by such as 
shall make the attempt, and who, moreover, will often find that they 
cannot retain it in the desirable place, without giving pain, and exerting 
so much force as to expose the os uteri to contusion or rupture. If 
the woman lies on her back, the fundus uteri will retire towards the 
spine, bringing its axis into the proper range ; and of course the plane 
of the os uteri will take its proper station: a child will, in some 
instances, be delivered much sooner if this precaution be taken, than 
if it be omitted. 

^Yhen we meet with patients who allow themselves to be violently 
agitated by the pains of labor, so as to require actually to be held, at 
a period when the perineum is in danger of rupture (and women are 
now and then so distressed as to lose all command of themselves), 
the best attitude is the one on the back, with the kness drawn up : in 
this position they are kept much stiller and quieter than when on the 



CONDUCT OF A LABOR. 287 

side. I had a woman under my care in November, 1833, who was 
so violent that two or three women could not keep her still: when I 
caused her to assume the dorsal position, she became passive enough. 

To assist the Flexion and Rotation. — I have spoken, in another 
place, of the dip of the occipito-frontal diameter of the foetal head. The 
nearer to the middle of the excavation we find the posterior fontanel, 
the greater is the dip. In the conduct of labors, we may exert a most 
beneficial influence, by paying due attention to the dip of the occipito- 
frontal diameter, which ought to bring the posterior fontanel down 
towards the axis of the excavation; not down to the axis, indeed, but 
yet, not too far off from it. The vertex must always, at first, be towards 
one of the lateral pelvic walls. But where the posterior fontanel is 
found quite up towards the side of the pelvis, and the anterior fontanel 
is at the same time within reach of the finger, we may feel assured 
that the dip has not taken place, and the retardation of the labor may 
safely be attributed to that cause. Could we, under such circum- 
stances, get the vertex down, or more towards the centre of the pelvis, 
the pains would be more successful. Now, as the edges of the parietal 
bones over-ride the edge of the occipital bone, they form a ledge, which 
gives a good purchase for two fingers, which, when applied upon that 
ledge, are generally enabled to draw the vertex downwards to the 
required position. Whenever this operation is to be attempted, it 
should be tried during the absence of the pains; and when the vertex 
is once pulled downwards, it ought to be retained in its place until a 
new pain comes on, and thus enables the operator to secure whatever 
advantage he has gained. Should the head be placed, by this gentle 
method, in the desired attitude, it is as easy to conceive, as it is in- 
deed common to witness, the increased facilities it affords for the 
delivery. 

In this case it is useful sometimes to make the womb take an 
oblique position in the belly. For example, suppose the vertex to be 
to the left, and to be unable to dip : it is clear that if the woman should 
lie upon her left side, and if the fundus of the womb should be thrust 
down towards the left side, the vertex would have less difficulty in 
descending. 

I have always found it much easier to pull the vertex down than to 
push the forehead up ; because, the finger, acting upon the ledge above 
described, does in reality act upon the longer end of the lever, of 
which the atlas represents the fulcrum; whereas, in an attempt to 
push up the forehead, so situated, the lever we use is very short — its 



288 CONDUCT OF A LABOR. 

I 

real extremity would be the chin; but we cannot reach that part. 
Moreover, when we attempt any strong force, the bones of the os 
frontis are so yielding, that they are readily indented, and we are 
obliged to desist for fear of contusing the brain ; the fingers, in fact, 
being applied near the upper edge of the os frontis, where the ossifi- 
cation is as yet very incomplete. The same objection does not hold 
as regards the posterior edges of the parietalia and os occipitis, which 
are very firm before birth. 

The labor may be retarded by the failure of the head to undergo 
rotation. It is sometimes very difficult, at the bedside, to learn 
wherefore the head does not rotate, in a patient, who, in another labor, 
meets with no such difficulty. I am aware that it frequently arises 
from failure of the dip above spoken of; but I wish now to speak of a 
case in which the head has sunk very low, where the dip is good, but 
yet the rotation fails : I have on many occasions, after much doubt 
and anxiety upon the subject, found that it could be fully accounted 
for, by referring to the grasp of the cervix uteri, which actually bound 
and held the head so firmly, that it was unable to execute its pivot 
motion. The remedy, in such cases, is patience ; for as soon as all 
resistance of the cervix is over, in consequence of the fatigue of the 
parts, or the acquisition of a perfect dilatability, the pains will push 
the head down, and the inclined planes of the pelvis will cause it to 
execute its spiral or rotatory movement in the most rapid manner. 

In all the cases where the rotation fails for want of the requisite dip, 
or approach of the chin to the breast, let that want be supplied by 
pulling down the vertex as directed. It must be admitted that such 
gentle measures will not succeed always, but we have, then, the 
powerful resource of the whole hand, which may be introduced into 
the vagina, and sometimes within the cervix; and which, taking the 
head in its palm and fingers can place the vertex wherever it may be 
desirable to fix it. It should be remembered, however, that a vectis 
is, very rarely, but yet imperatively, demanded for the management 
of such a case. 

To correct Obliquity. — The obliquity of the womb, which, by 
vitiating the direction in which its forces act, may greatly retard the 
progress of a labor, may also be a cause of failure both of the dip and 
the rotation of the head. Suppose the breech of the child to lie very 
low down in the right flank of the patient ; if the vertex be to the left 
side of the pelvis, the dip will be very difficult to effect, and the rota- 
tion must in consequence fail. The remedy is to correct the obliquity 



CONDUCT OF LABOR. VAGINAL VESICOCELE. 289 

by changing the position of the woman. It is easy to conceive, that 
if the vertex remain directed still to the left, and the breech could be 
now thrown far down to the left, the dip would be very much facili- 
tated. I have on many occasions reaped the benefit of attending to 
this point. 

Labors are rendered slow, painful, and even ineffectual, by vaginal 
vesicocele. The bladder of urine in these instances, instead of main- 
taining its place in front of the womb, appears to fall down below the 
top of the symphysis of the pubis, making a soft, elastic, and painful 
tumor there. Sometimes the depressed bladder is directed to one side 
of the pelvis, as in the following instance. 

Case.— Mrs. B.'s labor.— September 8th, 1848, 12 M. In labor 
since yesterday morning. Expected her confinement last month, 
about 15th to 20th. 

She recovered from her last menstrua November 10th, 1847, and 
has not seen since that date. If we adopt Prof. Naegele's method of 
calculation, and go back to October 10th, September 10th, and August 
10th, which is three months, and then add to August 10th seven days, 
we should look for the accouchement on the 17th August. In fact, on 
that day she had a considerable show, — which was repeated for many 
days, inducing her to keep her chamber, which she has not since 
left. Her pains are frequent and attended with violent tenesmus 
or bearing down. By the Touch I find the os uteri very high and 
scarcely to be reached ; open to the size of a ten cent piece, very thick 
and hard: the head presents ; the membranes unruptured. Having 
made this diagnosis and given some directions as to the conduct and 
prescribed for the tenesmic distress, I saw her again in the evening, 
about seven o'clock. The pains, it was said, had been repeated every 
few minutes ; and upon coming into the apartment, one would suppose 
the child was pressing the perineum violently, so loud was the sound 
of her respiratory effort in bearing down. 

She had passed the urine very often; the bowels had been moved 
by an enema. I immediately examined, expecting to find the child's 
head under the arch, but was surprised to discover that it had not 
advanced at all since mid-day. The os uteri might be as much as an 
inch in diameter and not more. Upon introducing the finger to the 
os uteri it appeared to encounter a sort of cushion-like tumor occu- 
pying the right half of the Excavation. On the left side of the Exca- 
vation there was nothing abnormal — the finger could be pressed to the 
left as far as the ischial plane. Upon discovering the tumor in ques- 
19 



290 CONDUCT OF LABOR. — VAGINAL VESICOCELE. 

tion, my first impression was that it was a case of pelvic enterocele like 
that in Dr. Bicknell's patient; but farther exploration showed that it 
was not in the recto-vaginal peritoneal cul-de-sac — which cleared up 
the diagnosis on that point. I asked again as to the urination — which 
had been frequent and free. 

I introduced a catheter into the urethra — but when it had advanced 
about two inches it stopped, nor did any urine escape. I expected to 
carry the point of the catheter downward and backwards into the 
tumor, which I now presumed could be nothing else than a cystocele, 
consisting of the bladder of urine which had been crushed under the 
womb and obstructed so as to be unable to discharge the whole of its 
contents. Finding I could not cause the catheter to advance without 
using imprudent violence, I withdrew it. The patient laid on the back 
with the knees drawn up. Introducing three fingers of the right 
hand far into the pelvis, when the pain was off, I pressed the palps 
of the fingers upon the inferior surface of the mass, and lifted it 
upwards towards the plane of the superior strait. Just as I had raised 
it partially up, there came on a violent tenesmic effort — and the urine 
rushed from the orifice of the urethra in jets so violent as to surprise 
me. In the course of three or four such jets, the whole of the urine 
in the bladder was expelled ; the tumor disappeared, and within forty 
minutes, the whole of the remaining dilatation of the cervix was 
completed and the child born. 

As soon as the bladder was emptied, the singular, extraordinary 
tenesmic efforts returned no more — but the phenomena of expulsive 
action were thenceforth perfectly natural and customary. 

The patient, when I came into her apartment, was found to be in a 
state of extraordinary excitement, representing her sufferings as intole- 
rable, her face redly flushed and heated, and the pulse rapid and 
irritable. 

This case seems to me worthy of record. First as presenting an 
example of the bladder crushed beneath the uterus. Second, as 
exhibiting the method of making diagnosis of such a case. Third, 
as showing how it may be successfully treated. And fourth, as proving 
that pains and distresses that contravene the co-ordinate action of the 
uterus in labor, being removed, the conformable play of its forces 
may be expected to take place. In this very case, even the dilatation 
of the cervix was held in suspense until I relieved the bladder; 
whereupon, the co-ordinate operations of the womb being no longer 
contravened, they effected the delivery in forty minutes. 

September 18. The patient is sitting up to-day. She has no 



CONDUCT OF LABOR. THE CERVIX AND OS. 291 

urinary distress, and has not had any complaint since the birth of the 
child, save a feeling of soreness and aching in the pelvis which lasted 
only a few days. 

Management of the Cervix and Os Uteri. — The head has sunk 
low into the Excavation ; the fontanel is in the proper position, neither 
too near to, nor too far from the symphysis : but it advances not at all ; 
pain after pain passes over, with great suffering to the mother, and 
yet with no sensible advance to the head. What can occasion the 
retardation ? The finger passes up behind the symphysis to the supe- 
rior strait, and moves along the linea ileo-pectinea a considerable dis- 
tance, showing conclusively that no disproportion exists between the 
head and the bony canal it is destined to traverse. All uneasiness of 
mind on the practitioner's part will cease as soon as he discovers that 
the cervix uteri, which he had thought to be sufficiently dilated to 
offer no farther considerable opposition, has ceased for a time to yield, 
and takes hold of the head during every pain, in such a manner as to 
prevent the parietal protuberances from escaping into the vagina. 
The proper remedy here, also, is patience; a small venesection; a 
large draught of some warm relaxing fluid ; the fortunate occurrence 
of nausea; a careful adjustment of the axis of the uterus, and of that 
of the pelvis ; or perhaps a few very powerful exertions of the auxil- 
iary muscles in bearing down, to which the woman can be exhorted. 
I have often, after allowing myself to get into a fret relative to the 
slow progress of affairs, found all my uneasiness dissipated by a more 
careful examination ; thus, as above, clearly ascertaining that no other 
than soft obstruction existed; whereas, from too careless an examin- 
ation, I had been erroneously led to believe that the os uteri had 
mounted up over the parietal protuberances of the foetal head, and that 
some unknown cause of retardation existed. 

Effects of a bad Sacrum. — The hollow of the sacrum is the es- 
sential cause of the specific properties of the excavation. Those pro- 
perties will be present in perfection, where the sacrum is perfectly well 
formed and adjusted: but the sacrum may be either too little curved 
or too much so. I have specimens of both kinds of deviation. Inas- 
much as the rotation of the head requires, for its regular and easy per- 
formance, a good curve in the sacrum, it is striking, that a very 
straight sacrum must offer considerable impediments to that important 
act. Hence, a sacrum with too little curve will protract the period of 
delivery; and in fact, a case might arise, and such a one has arisen, 



292 CONDUCT OF LABOR. LONG SYMPHYSIS. 

-where no rotation at all could take place, but where the delivery, at 
last, must occur without this important act in the mechanism of 
labor — the vertex coming out under the tuber ischii : a case requiring 
the very extremest degree of flexion of the head. Let the Student 
reflect a moment, and he will perceive what process must be substi- 
tuted for the rotation. The occipito-bregmatic diameter is but three 
and a half inches, but the tubera ischii are four inches apart ; hence, 
where the rotation fails, there must occur a greater dip, causing the 
occipital fontanel to take a position nearly in the centre of the pelvic 
canal, by which the relations of size between the head and pelvis are 
restored, and the occipital bone is enabled to pass out under the 
ischium, and the parietal protuberance under the pubal arch. Such 
a great degree of dip may be much promoted by the help of the 
fingers, as before stated, but it will take time. It is not very difficult 
when the head is of a medium size. 

On the other hand, if the sacrum be too much curved, its apex will 
jut forwards towards the pubis, so as to form a sort of shelf, on which 
the head lies ; the expulsive forces being, for a long time, vainly ex- 
pended in impelling the head down upon this shelf or ledge. The 
gradual compression of the cranium, however, at length moulds it 
into the requisite form, and allows it to slide off the ledge, and the 
delivery takes place. It is to be understood, that the very aggravated 
degrees of this vicious conformation involve the necessity of direct 
interference with some one of the various instruments employed in 
obstetric operations. 

Influence of a badly shaped Pubis. — When the pubal arch is 
not low, but retains the character of early life or of the male pelvis, it 
happens that great retardation takes place; because the act of exten- 
sion of the head cannot happen in due time. Such a narrow arched 
pelvis compels the head to continue its descent much longer than one 
where the arch is broad and low. It has as bad an effect as, and in- 
deed it is equivalent to, a long symphysis pubis ; for in the ordinary 
conformation, as soon as the occipital bone can come to apply itself 
to the arch, the vertex begins to rise ; extension of the head taking 
place, and the perineum requiring no inordinate degree of protrusion. 

But imagine a pubic symphysis of two and a half inches, instead of 
one of an inch and a half, and it is plain that the perineum must go 
farther down before the head can escape under the arch. 

Case. — A patient with a very narrow arch had been under my care 



CONDUCT OF LABOR. — THE PERINEUM. 293 

in two of her labors, in which, the natural pains being insufficient, I 
was compelled to augment them by the ergotic stimulation. By vio- 
lent efforts of the womb and abdominal muscles, she gave birth in both 
cases to living children. I need not say, in self-defence, that I waited 
as long as I deemed it prudent to do so, but my confidence in her 
strength was vain in each instance. In 1841, I delivered her for the 
third time; but was obliged to use the forceps. 

The Perineum. — The resistance of the perineum and vulva are so 
great, in many women, as seriously to retard the delivery. I have 
waited six hours by the bedside, after the vertex has begun to jut out 
between the labia, the patient all the while suffering severe labor pains, 
which vainly tended to expel the head. In such cases there is nothing 
to be done but wait patiently, after having placed the woman's con- 
stitution in its proper attitude by means of venesection ; by every 
psychiatic resource of exhortation, assurance, encouragement, and 
honest promise of relief; by the least fatiguing posture of the body ; 
by the application of mucilaginous fomentations to the genital region; 
by the exhibition of relaxing drinks, and by the warm bath. I con- 
sider that we have no right to apply a force, additional to one that 
nature furnishes, and which it is evident must be effective if left to 
itself. Under such perverse resistance of the soft parts, time is re- 
quired to enable them to acquire a yielding temper. To force the 
head through them by the ergot or the forceps, would be to incur the 
hazard of shocking lacerations of the external organs of generation, or 
even of the womb itself, which it is rashness, in the highest degree, 
to stimulate and lash into fury, in cases where the uterine contractions 
are already very powerful, and where they would soon effect the de- 
livery, were it not that the external parts are unprepared to admit of 
it. The true principle of practice here is, to diminish the resistance, 
and not to increase the power, already perhaps excessive, and therein 
dangerous. Let me be fully understood as referring, in the above 
remarks, only to cases where the energies of the uterus are great and 
manifest, but yet unequal to the task of overcoming the resistance 
rapidly, and where they evidently will overcome it in a reasonable 
time. In other circumstances, as where the resistance is powerful 
and the pains poor and weak, let the just proportion be established, 
by means of the ergot, a glass of wine or the forceps, between the 
power, and the resistance it is destined to vanquish. Three years 
ago, I attended a young woman in labor with her first child. The 
process was most painfnl and tedious. The head was fully six hours 



294 CONDUCT OF LABOR. — THE PERINEUM. 

pressing upon the perineum and external parts, under violent uterine 
contractions. The child was at length born, but was dead. As this 
was a result which I very much feared, I was extremely desirous of 
applying the forceps. Would it have been justifiable to use them in 
a case when the contractions were so strong as to lead me to apprehend 
that the perineum would give way under every natural pain? I think 
not. 

It is perhaps impossible to find expressions fitted justly to set forth 
the tormenting doubts and anxieties of the accoucheur in cases like 
this; cases where he feels that he has power to terminate the suffer- 
ings of his patient, but dares not violate the injunctions of his con- 
science, which tells him he may not yet intervene. 

When, at last, the head begins to emerge, it does so by pushing 
away the perineum before it, which continues to cover the cranium 
like a tight cap. It should be remembered that the direction of the 
forces is parallel to the axis of the superior strait ; but it is equally 
true that the direction of the movement is not in the same line, at this 
stage ; the head is repelled by the curved line of the sacrum ; it is 
driven against the sacrum, but, coincidently, w T ith Carus's curve, 
vide Fig. 23, page 47, glides off from its curved surface towards the 
outlet; from which, if unrestrained by the perineum, it would escape 
without much extension. It has happened that the head has passed 
directly through the perineum, perforating it as if a six pound ball had 
passed through it, without injuring the commissure of the vulva, or the 
sphincter muscle of the anus; and there is supposed, always, to exist 
some danger of its tearing the anterior edge of the perineum, at least, 
when that point is unsupported. Hence the general care of writers 
to direct that the perineum be supported. 

From the foregoing remarks, the Student will be enabled to appre- 
ciate the value of this injunction concerning support to the perineum, 
and to know how it ought to be executed. He knows that a towel 
should extend from the lower part of the sacrum up towards the top 
of the vulva, and be pressed against the parts in such a manner as to 
protract or continue the inclined plane of the sacrum, whereby exten- 
sion of the head will be enforced, and no danger occur of its being 
too strongly propelled against the now thin tissues, which might be 
lacerated were the head not to follow the curved line of its movements. 

The degree of pressure made by the hand must be proportioned to 
the exigencies of the particular case. It should be always sufficiently 
great to cause the head to undergo extension, at least; and, where the 
tissues yield with difficulty, so as to furnish grounds to fear their 



CONDUCT OF LABOR. THE CORD THE SHOULDERS. 295 

laceration, the further advance of the head may be safely counteracted, 
for a time, by firm pressure, which should be continued until the soft 
parts acquire a proper dilatability. 

The young practitioner, and the Student, should be warned against 
falling into a habit of beginning too early to support the perineum. 
If the part should be too early pressed upon with a napkin, it might 
become heated, and thus lose its disposition to dilate: and it is 
assuredly not necessary to sustain it, or support it, until so great a 
degree of extension has taken place as to put it in some danger of 
being lacerated. 

Cord round the Neck. — The head is born : perhaps the cord is 
turned once, or even more than once around the child's neck, which 
it encircles so closely as to strangulate it. Let the loop be loosened, 
by pulling the yielding end of the cord, sufflcently to enable it to be 
cast off over the head. This cannot always be done : if so, in any 
case, let the child pass through it by slipping it down, along its body, 
over the shoulders. If it seems impossible to slip the cord over the 
head or shoulders either, it should be let alone : and in a great majority 
of cases it will not prevent the birth from taking place, after the 
occurrence of which, the cord can be cast off. Should the child 
seem to be detained by the tightness of the cord, as does rarely hap- 
pen, or in danger from the compression of its jugular vessels, the 
funis may be cut with the scissors, and tied after the delivery. Under 
such a necessity as this, a due respect for one's own reputation should 
induce him to explain, to the by-standers, the reasons which rendered 
so considerable a departure from the ordinary practice indispensable. 
I have known an accoucheur's capability called harshly in question 
upon this very point of practice. I never felt it necessary to do it but 
once. 

The Shoulders. — If the shoulders should not rotate, so as to bring 
one of them under the arch, that motion may be given by one or two 
fingers, introduced, and made to act upon the shoulder nearest the 
pubis, so as to draw it into its proper place. If difficulty occur, and 
the shoulder does not advance, press the child back against the edge 
of the perineum, and that will often afford room for the advance of 
the shoulder, which had been thrust over the top of the brim of the 
pelvis by the resiliency of the edge of the perineum which is pressed 
against the posterior part of the child's neck, whereby it pushes 
the opposite side of the neck against the pubis. I have sometimes 



296 CONDUCT OF LABOR. THE CHILD. 

caused the shoulders to descend immediately, by merely pressing 
the perineum downwards and backwards ; the child, whose shoulder 
was jammed up above the top of the symphysis pubis, slipping down 
behind the symphysis, as soon as the cause that pushed it forwards 
(namely, the pressure of the perineum) was withdrawn. Sometimes 
the shoulder nearest the sacrum, and at others that nearest the pubis, 
escapes first. The student will, in practice, readily perceive which one 
he ought to assist; he will at times be compelled to try one, and then 
the other, being uncertain which is likely to emerge first. 

It is considered bad practice to drag out the body, except in very 
particular circumstances — the womb and abdominal muscles are 
sufficiently powerful for that object ; and if it be permitted to come 
away slowly, we shall have a more complete contraction of the 
womb, and a more ready detachment and extrusion of the placenta. 
Therefore, it is better to leave the expulsion of the body to nature, 
merely removing any cause of delay, that may obviate its descent 
and escape. "Where the delay is great, and the child becomes very 
black in the face, and the respiration is either not established or in an 
unpromising condition, we are fully warranted to expedite the delivery 
by making use of one or more fingers, fixed as a blunt crotchet in the 
axillae. 

How to treat the Child. — As soon as the child is born, lay it on 
its back, out of the reach of the waters, which sometimes stand in a 
deep puddle by the breech of the mother — the child ought never to be 
exposed to the danger of suffocation. If it breathes regularly, it is 
well ; if not, blow suddenly into its face, and drop some cold spirit 
on to the region of the diaphragm. These and a few smart frictions 
are, in general, all that are demanded. Take care that the infant be 
not too rudely or suddenly handled. It ought not to be agitated by 
any violent or hasty motions. In many of the instances, life is already 
nearly extinct, and so, the child can no more endure to be rudely 
handled or shaken than can a fainting girl. It is enough to see and 
know that the child lives. That its heart is beating and its diaphragm 
moving — for these are the two great motives of life. If the diaphragm 
moves it pours the oxygen upon the blood — but, oxygeniferous blood sent 
forward to the brain by the contracting heart excites the biotic force 
in the neurine. That force is life made manifest in motion. The 
cord should not be cut until the pulsations have ceased near its 
placental extremity: it would be vain to wait for its cessation near the 
child's body, as doubtless blood is thrown into the arteries long even 



CONDUCT OF LABOR. THE PLACENTA. 297 

after the ligature is applied ; in fact, children do sometimes bleed at 
the cord hours after they have been dressed, if the cord have been 
imperfectly secured. There is no need to tie the cord twice, unless 
there be twins; w T hich can always be ascertained by feeling for the 
uterine tumor. Tie only one ligature, and that at the distance of an 
inch or two from the belly, and cut the navel string, holding the cord 
tightly betwixt the finger and thumb. If it be not held, it will spurt 
the blood sometimes to a good distance, and soil the bed, or even the 
practitioner's clothes. Conceal the cut end of the placental portion 
of the cord in the napkin with which the perineum has been defended, 
in order that. its blood may not fly over the bed; and then, give the 
child to the nurse. There is danger of dropping the infant if it be not 
properly taken hold of. It should be seized with the left hand, by 
one or both ancles ; the back of its neck ought to rest in the arch 
formed by the thumb and forefinger of the accoucheur's right hand, 
while its back lies in his palm, and the points of the remaining three 
fingers are under its right axilla. If held in this manner, it can by 
no means fall to the ground. I have seen a child taken hold of under 
the arms by both hands, and lifted up in a manner I thought quite inse- 
cure, considering that it is slippery with the waters or blood from 
which it had just been taken up. 

Placenta. — In most cases the placenta comes away in eight or ten 
minutes — Dr. Hunter thought in twenty minutes. The care required 
in regard to the placenta is considerable ; for no one can say, of any 
labor, that it will end well, until the after-birth is completely dis- 
charged, and for at least an hour after that consummation. The 
French call the delivery of the placenta, emphatically, deliverance, 
delivery. We ought always to ascertain, after having given away 
the child, what is the state of the womb. To that end, place a hand 
on the hypogastrium, and if a hard tumor be felt there, the womb is 
contracted ; if the womb is either not to be felt at all, or is very soft 
and yielding, or very large, a few T gentle frictions on the abdomen 
will cause it to contract ; and now if a finger be passed up to the os 
uteri, the after-birth will be felt either in it, or just above it; if in it, 
let the woman bear down immediately, wmile the cord is tightened, 
by pulling moderately at it. The mass will descend slowly into the 
vagina, either edgewise or not ; if not edgewise, one edge may be 
hooked down w 7 ith the finger, and a few efforts of bearing down will 
expel it from the vulva. It should be received in the left hand, and 
turned or twisted round several times by the right hand, in order that 



298 CONDUCT OF LABOR. RETAINED PLACENTA. 

the membranes may be gathered into a string or rope, so that, when 
they are drawn out, none of them need be left adhering to the ute- 
rine surface, where, by detaining portions of blood, they might give 
occasion to putrefaction, with offensive and injurious discharges. A 
complete, clean delivery ought always to be effected, if possible. If 
the woman finds, the next day, that portions of membrane are hang- 
ing out of the vulva, she becomes alarmed, or at least thinks her 
medical man careless or ignorant. Notwithstanding that the pla- 
centa may be carefully rolled, as above directed, we sometimes find 
that where the membranes have been very much broken by the child, 
or where they are extremely delicate, the cord we have formed by 
twisting them, is breaking, so that a considerable remnant of them is 
about to be left in the uterus, which we cannot get possession of, 
without passing up the hand at least into the vagina. My custom, 
when I find the membranes breaking, is to cease pulling until I have 
wrapped them in a small rag, which enables me to twist, them still 
more, and thus draw them entirely away. Now they are so slippery 
that they cannot be twisted with the fingers, but when a dry rag is 
wrapped round them, we can twine them, and pull them as much as 
we may think needful. 

Retained Placenta. — It unhappily does not always befall that the 
placenta comes away soon ; we may wait half an hour or an hour, for 
the expulsion of the after-birth, and yet upon examination, repeated 
from time to time, discover that it has not come within reach of the 
finger. Frictions upon the abdomen are known powerfully to excite 
the peristaltic fibres of the alimentary canal ; but their effects upon 
the womb are far more decided: it maybe said, that when made 
upon the hypogastrium, they generally compel the womb to recom- 
mence its contraction — some wombs are so excitable that a touch 
brings on the after-pains; they ought, therefore, to be instituted. 
The consent of parts, also, causes the womb to act sometimes, as 
soon as the woman makes a strong bearing down effort, to which she 
should be urgently prompted, if needful. When a contraction has 
been procured by frictions, or in any other way, it may be rendered 
permanent by pressure; therefore, let an assistant be properly taught 
to apply the palm of the hand over the uterine globe, and not take it 
off, until told to do so. Such assistant, however, ought to be one 
worthy of the trust; an ignorant one might, by pressing at an incon- 
venient moment, indent the soft and relaxed fundus uteri, and thus 
cause the beginning of an inversion of the organ. I have no doubt 



CONDUCT OF LABOR. — HOURGLASS. 299 

that some of the cases recited in the books were brought about in 
this way. In all those patients who habitually flood in labor, this 
precaution ought to be observed. When the hand is removed, a 
bandage should be ready to occupy its place. If the os uteri be 
very much closed, it is probable that the placenta will require a 
long time to come away ; and I know no objection to a patient wait- 
ing for the spontaneous movement of the organ, where no hemor- 
rhage, or other unusual appearance is observed. Some writers have 
been disposed to assign a fixed period, up to which the accoucheur 
ought to wait, before he resorts to compulsory measures for the delivery. 
But there can be, or ought to be, no fixed rule on the subject, except 
this one rule, namely, the placenta must be got away, as there is no 
security while it is left. I have never gone away from a patient leav- 
ing the placenta undelivered. I think I have never waited for its 
spontaneous extrusion more than an hour and a half, for I have always 
supposed that if it would not take place in one hour, there was little 
prospect of its taking place in twenty-four hours. I cheerfully admit, 
however, that cases may and do occur, in which a longer delay might 
be advisable. I have not met with such cases. I wish to be under- 
stood as speaking, in this place, of the placenta retained in utero, and 
not of cases where it is partly expelled into the vagina; for, when in 
the vagina, I think there can be no necessity for waiting at all; it 
ought to be removed at once. Ruysch, the celebrated Dutch anato- 
mist, zealously inculcated the doctrine, that, as the expulsion of the 
placenta is a natural office, it ought not to be interfered with, except 
upon the occurrence of symptoms making such intervention indis- 
pensable; and his authority having been deemed unquestionable, was 
yielded to by several physicians of eminence, who nevertheless found, 
after losing not a few patients from hemorrhage, inflammation, &c, 
the consequence of retained placenta — that experience is the best 
teacher ; and they therefore reverted to the custom of securing the 
expulsion of the secundines by artificial measures, wherever the 
powers of nature were incompetent to that function. 

Hourglass Contractions. — As to placenta retained by what is called 
hourglass contractions, I am very confident in the assertion that it is 
always an adherent one. Where the connection of the placenta 
to the uterine surface has, by force of some certain inflammatory action, 
become preternaturally firm, the substance of the placenta acts as an 
internal antagonist to the contraction of that part of the uterus on 
which it sits. In fact, the placenta may be said to splint the womb, 



300 CONDUCT OF LABOR. — HOURGLASS. 

and keep its superficies extended. Now, when all the rest of the 
womb, except the placento-uterine region of it, is left without antago- 
nism, it contracts as usual, but the antagonized portion remains ex- 
tended, splinted by the after-birth, so as to be incapable of contract- 
ing like the rest, which, of course, by their contraction, shut the pla- 
centa up in a cell, a cavity, which is the upper cavity of the before- 
mentioned hourglass. I have never seen an hourglass contraction 
without adherence of the after-birth, and I take it for granted, that as 
soon as an hourglass contraction is discovered, there is discovered 
along with it the indication to deliver, there being no reasonable 
hope that a spontaneous delivery will take place. I freely, therefore, 
advise the reader to deliver at once in all cases where the existence 
of an hourglass contraction can be clearly made out. This operation 
maybe performed so as to give no great pain; it requires to be 
always attended with explanation of the necessity, and assurances 
of great carefulness and tenderness in the performance of it. Half 
the hand should be insinuated into the ostium vaginae first, as far 
as the thumb, which being next buried in the palm, permits us to 
get the whole hand into the pelvis. From thence, either the whole 
hand, or half the hand, or sometimes the index finger alone, may be 
made to enter the cavity of the Womb, to detach and seize upon the 
placenta, which, when fairly severedr of its unnatural connection to 
the uterine wall, may be removed by the hand, or left to be expelled 
by the contractility of the organ. It is a very safe and proper con- 
duct, however, to bring it away in withdrawing the hand, so as to let 
the uterus contract as much as possible. 

A placenta will weigh from a pound to a pound and a half. Let 
the Student reflect that such a mass, if within the uterine cavity, 
must distend it considerably ; and if he cannot touch it by passing 
the finger up to the os tincse, the fundus of the womb must, of course, 
be high up within the abdomen. Therefore, in any case of retained 
placenta, he will find the fundus perhaps fully as high up as the 
navel. It will require, then, in order to get it, that the hand should 
be introduced: the finger cannot reach far enough. 

From the dilated state of the vulva and vagina, after delivery, no 
difficulty stands in the way of the introduction of the hand into those 
parts. As it passes up it is guided by the forefinger, which glides 
along the cord, while that is tightened by the other hand. The reader 
must expect to find instances in which the os and cervix uteri actually 
gripe the chord ; and that he will be, in such a case, necessitated to 
introduce only one finger at first, then a second, and a third, which 



CONDUCT OF LABOR. — HOURGLASS. 301 

gradually conquer the resistance of the circular fibres of the os and 
cervix uteri, so as to make way for the whole hand, which at length 
is found to have entered into the cavity of the womb. But the pres- 
sure required in this operation has put the vagina, even the womb 
itself, on the stretch ; so that were he not to resist its rise by pressing 
the abdomen with the other hand, the fundus would be pushed up to 
the scrobiculus cordis, and his arm pass inwards as f&r as the elbow. 
In general, it appears to me that the uterus, in retained placenta, con- 
tracts by its cervical or lower horizontal fibres, while its longitudinal 
contraction does not take place at all. It is, indeed, extremely common 
to feel the womb, like a large intestine, pretty firmly contracted as to 
its transverse diameter, while from the fundus to the os uteri the length 
is not much less than before the commencement of labor. Certainly 
it must have happened to many practitioners to make this remark of 
the cases in which they were obliged to introduce the hand, for the 
extraction of the placenta. Let the operator always stop the womb 
from rising, by counteracting it with one hand placed on the abdomen, 
over the top of the fundus, in order to push it downwards towards the 
hand which is within. Most probably the placenta is to be found 
wholly or partially detached ; if not, let the detachment be effected, 
taking great care not to use sudden and indiscreet force, so as to 
hazard the leaving any of its lobuli in the cavity of the womb. When- 
ever all the adhesions are certainly overcome, the mass should be 
grasped in the hand, which may then be gradually withdrawn, hold- 
ing the obnoxious placenta in its grasp ; or, if the womb is suffered 
to push the hand out, so much the better. This operation it has been 
my fortune to be compelled to perform a good many times ; and I can 
safely say I have never seen any bad results from the practice. I re- 
peat, it may be done so gently and dexterously, as even to occasion 
but little pain. No patient for whom I have performed this service 
has died. 

When the last portions of the child quit the uterine cavity, being 
expelled by the muscles of the organ, it generally happens that the 
placenta is completely detached from the uterine wall by that same 
contraction. This, however, is far from being always the case. 
When the womb does not displace the placenta by the force of the 
last expulsive effort, it does not follow that we are to expect an hour- 
glass contraction. On the contrary the hourglass is a rare event, 
while the continued adherence, total or partial, is a common one, 
the partial being more common than the total adherence. If, in 
such a case, there be no flooding or other symptoms indicating our 



302 CONDUCT OF LABOR. UTERUS AFTER DELIVERY. 

intervention, we ought to wait for one hour at least. It is not wise, I 
think, to wait longer, and my multiplied experiences teach me that it 
is not rash to proceed to the delivery of the secundines. To do so the 
whole or part of the hand must be passed upwards, so as to reach and 
peel off the placenta. 

The cord furnishes a most convenient means of pulling out the 
placenta, but should never be used for that purpose without a very 
careful reflection on all the circumstances. If the after-birth is still 
attached, and the uterus firm, to pull at the cord is to endanger the 
breaking it off even with the surface, which is an embarrassing and 
rather disgraceful accident; but if the womb be not firmly contracted, 
it is so flaccid, that, like a wet bladder, it may be turned inside 
out. I have seen a womb that was turned inside out by a midwife in 
this way, a case of great interest, that will form the subject of a future 
page. To any individual who has seen a womb at full term, nothing 
would seem to be easier than to invert a relaxed uterus. Wherefore, 
no man of discretion ought to draw by the umbilical cord, without 
having first ascertained that the womb is well contracted; and even 
then, the force he may venture to employ by its means is an exceed- 
ingly limited one. 

Womb after Delivery. — W T hen the placenta is delivered, the 
hand should be soon placed on the patient's hypogastrium, for the 
purpose of ascertaining whether the uterine globe is firm. If you for- 
get to do this, you will incur the dreadful hazard of leaving your 
patient with an inverted womb. This lately happened here to a friend 
of mine, who did not discover the accident until five weeks after the 
event. The woman suffered the greatest distress, and the greatest 
weakness from loss of blood, but recovered at last. 

It ought to feel through the integuments about as large as the fist; 
but there is great diversity in regard to the magnitude of the organ 
immediately subsequent to delivery. The smaller it is the better for 
the patient, who, with a well contracted uterine globe, may be safely 
pronounced beyond the reach of danger from effusions of blood ; or at 
least, from effusions that can with propriety be denominated uterine 
hemorrhages. 

In feeling for the globe of the womb, we should always endeavor to 
ascertain that the fundus has not fallen in, making a deep concavity 
like that in the bottom of a junk bottle. Such an indentation is the 
first beginnings of inversion of the womb, and it may readily be de- 
tected where the belly is loose, thin, and flabby. If, in any case, 



CONDUCT OF LABOR. AFTER-PAINS. 303 

such an indentation should be discovered, the rule of practice ought 
to be to introduce the hand and take the placenta bodily away, for- 
bidding the woman, meanwhile, to make even the least expulsive 
effort. After the extraction of the after-birth, great care should be 
used to make sure that the proper orbicular form of the organ is pre- 
served. 

After-pains. — Inasmuch as the pains of labor alternate with inter- 
vals of rest or inaction, it follows that the pains which women suffer, 
whether before or after delivery, depend upon one and the same cause, 
namely, the alternate action of the womb. The organ, after delivery, 
grows alternately small and large for some hours ; expanding to 
double the size of the fist when the pains are off, and reducing itself 
to the smallest size when they return. Every interval, or moment of 
expansion, permits a small quantity of blood to accumulate in the 
cavity, which is soon forced out by the returning pains. The woman 
feels the gush of warm fluid issuing from the vulva, and is very apt 
to say that she is flooding or flowing. An inspection of the counte- 
nance and an examination of the pulse are perhaps sufficient to indi- 
cate the course of the practitioner. If the face is not pale, and the 
pulse not weak or small, he will be sure she is not bleeding too freely; 
but if they indicate the existence of too considerable a discharge, the 
amount of it ought to be ascertained with the most rigorous precision. 
There are few nurses who are competent to decide upon the nature of 
the discharge; as whether it amounts to what might be denominated 
hemorrhage or not. I was called in haste to attend a woman whom 
I found just delivered of a child ; I received the after-birth, which 
came off spontaneously, and observed that the sanguine discharge was 
very great, but the woman, although feeble, was not sunken. The 
uterus contracted well, and I left her in a comfortable and usual state. 
In about two hours I was summoned again, and found her very faint, 
with extremely feeble, slow pulse. Placing one hand upon the hypo- 
gastrium, I found the womb not dilated, and then inquired of the 
nurse as to the amount of the lochia. She assured me that it was not 
greater than it should be. She had examined carefully into the cir- 
cumstances and found all right. Distrusting her account, I determined 
to learn for myself whether a large effusion had taken place, and found 
an immense quantity of coagula lying upon the bed, which the nurse 
had either not seen at all, or disregarded. This case, which after- 
wards caused me great trouble and anxiety, has influenced me ever 
since, and now I always feel unwilling to take information at second 



304 CONDUCT OF LABOR. — HEMORRHAGE. 

hand upon the important subject of profuse uterine discharges. I 
think it the duty of the Student early to resolve to learn accurately 
whatever may have an injurious or dangerous tendency for the patient 
to be committed to his charge. 

Hemorrhage. — It may be stated as an axiom in obstetrics, which 
has almost no exception, that a well contracted uterus cannot bleed; 
and all obstetricians habitually feel secure when they find the organ 
hard, and of a small size. Nevertheless the state of contraction may 
soon be followed by so absolute a relaxation of the contractile forces 
of the uterus, that the gentlest infusion of blood into its cavity is 
capable of distending it again, if that fluid be prevented from escaping 
at the os tincse or at the vulva. But if a coagulum should fill the 
vagina, or stop the mouth of the womb, or if the napkin should be 
too strictly pressed against the genital fissure, preventing the escape 
of fluid therefrom, the blood which flows into the womb will gradually 
distend it to that degree, that, without losing a spoonful externally, the 
woman may effuse enough blood into the uterine cavity to expand it 
very greatly, and to cause fatal syncope. 

Case. — I was called, about three years ago, into the country, to assist 
a practitioner in a difficult labor. When I arrived, the child had just 
been delivered with forceps. The placenta was adherent. After 
waiting a sufficient length of time for its spontaneous extrusion, I 
removed it, and the womb contracted well. In the course of half an 
hour my attention was attracted by a sort of gurgling sound from the 
bed, which caused me to draw near to the woman, whom I found 
already quite fainted away when I approached her. She was very 
pale, and the pulse could not be felt at the wrist. The discharge was 
inconsiderable ; but on placing the hand on the hypogastrium, the 
womb was found enormously distended, and full of blood. Two 
fingers were now carried into the os uteri, which was found to be 
tamponed with a very firm clot. This I broke up and brought away, 
when out rushed a large quantity of grumes, mixed with fluid blood, 
and the womb returned to its proper dimensions. She had no return 
of the symptoms. 

I could cite many examples from my case book, of violent hemor- 
rhages, both concealed and open, which have fallen under my notice 
in females where the uterus had contracted perfectly well after the 
delivery of the placenta. One case is so remarkable that I cannot 
resist the inclination to publish it here. 



CONDUCT OF LABOR. HEMORRHAGE. 305 

Case. — Mrs. S. was delivered of her first child after an easy labor. 
She had a very good getting up, and on the fifteenth day walked down 
stairs. Some words of an unpleasant character passed between her 
and her husband. She became violently excited with anger; then 
burst into tears, and ran up stairs, where she threw herself on the bed. 
She was shortly afterwards found in an apparently dying state. When 
I reached the house there was no pulse ; great coldness, and the greatest 
degree of paleness. I found the womb filled with blood, and reaching 
above the umbilicus. Dr. Dewees was so kind as to visit this patient 
with me, and assist me with his valuable counsel. She recovered, but 
suffered a long time under the symptoms produced by this excessive 
sanguine discharge. This case will show the Student that even where 
the uterus has contracted so much as to sink down below the superior 
strait, it may be afterwards enormously distended by influent blood ; 
and the reflection arising from it, though an unpleasant one, is a very 
just one, that even w r here we succeed in getting a good contraction, we 
can have no sense of absolute security against concealed or open 
hemorrhage, in a patient whom w 7 e may have put to bed ever so 
comfortable, and apparently safe. 

The influence of position in determining the momentum of blood 
in the vessels is well known to the profession ; but there are few cases 
where it is of more consequence to pay a profound regard to this 
influence, than in parturient women. A uterus may be a good deal 
relaxed or atonic, and yet not bleed, if the woman lie still, with the 
head low; whereas, upon sitting up suddenly, such is the rush of 
blood down the column of the aorta, the hypogastrics, and the uterine 
and spermatic arteries, that the resistance afforded by a feeble contrac- 
tion is instantly overthrown, and volumes of blood escape with an 
almost unrestrained impetuosity. The vessels of the brain under such 
circumstances become rapidly drained, and the patient falls back in a 
state of syncope, which now and then proves immediately fatal. I 
may be excused for stating here (Aug. 1841), that I have never met 
with one of these sudden and fatal hemorrhages in my own practice. 
It is, perhaps, due to the special attention I have always considered it 
a duty to pay to this point, that I have hitherto avoided so serious a 
misfortune. Surely, I have, in a multitude of persons, by a prompt 
attention to the state of the womb, turned aside the stroke of death by 
proceeding without delay to empty the organ by turning out of its 
cavity with my fingers the masses of coagula with which it was filled. 
If you leave your patient soon after her deliverance and are hastily 
recalled to see her w r ith an announcement perhaps that she is dying, 
20 



306 CONDUCT OF LABOR. HEMORRHAGE. 

your first duty on reaching her bed-side is, to examine the hypogaster 
in order to ascertain if the uterus be firmly contracted or not. 

Case. — In conversation with my late venerable friend Professor 
James, upon this very subject, he informed me that he delivered a 
lady a few years before, after an easy natural labor. The uterus con- 
tracted well, and all things seemed as favorable as possible. As the 
accouchement took place early in the morning, he was, subsequent to 
the event, invited to breakfast down stairs, whither he proceeded, after 
having given strict caution to the lady on the subject of getting up. 
"While the persons at breakfast were conversing cheerfully, and exchang- 
ing felicitations upon the fortunate issue of affairs in the lying-in 
room, the nurse was heard screaming from the top of the stairs, 
"Doctor, Doctor, for God's sake come up!" He hastened to the 
apartment, and the lady was lying across the bed quite dead. It was 
found that, soon after the doctor went below, the lady said to the 
nurse, "I want to get up." "But you must not get up, madam, the 
doctor gave a very strict charge against it," replied the nurse. "I 
do not care what the doctor says," rejoined the patient ; and thereupon 
arose, and throwing her feet out of the bed, she sat on the side a few 
moments, reeled, and fell back in a fatal fainting fit. The remarks 
of Dr. James, as he related the occurrence to me, have made upon my 
mind a deep impression of the vast consequences of careful and well- 
timed instruction of the nurses ; who, if they could have the dangers 
of mismanagement fully exposed to them, would surely avoid some 
accidents that every now and then are attended with very shocking 
results. 

Large discharges are not apt to occur when the womb has once 
contracted pretty firmly. But there are precautions which ought 
always to be observed : for example — 

Case. — I left a woman half an hour after the birth of her child. 
She was as well as could be desired. I gave the usual directions. 
In a short time her husband came running to me, in the street, where 
he met me, and said his wife was dying. Upon hastening to his house 
I found her, in fact, pulseless, pale, and completely delirious, with a 
constant muttering of incoherent phrases. Upon inquiry, the following 
occurrences were found to have taken place. She felt some desire to 
pass the urine. The nurse told her to get up. "But the doctor says 
I must not get up." " Oh, never mind what the doctor says, it won't 
hurt you; get up." A chamber-pot was placed in the bed, and Mrs. 



CONDUCT OF LABOR. HEMORRHAGE. 307 

F. was lifted upon it, in a sitting posture. She fainted in the 
woman's arms, was held up a short while, and, when laid down, the 
vessel was discovered to be half full of blood. She had nearly died ; 
and did suffer long and severely in consequence of this imprudent 
disregard of orders. When I left her, the uterus was well contracted ; 
but the change of momentum in the arterial columns produced the 
hemorrhage, than which I have scarcely seen one more dangerous. 

Case. — It is of the highest consequence to secure a powerful con- 
traction of the womb after delivery, in all those women who have 
suffered severely from floodings, occurring soon after the birth of the 
child. A lady in three successive labors, of which the first occurred 
on the 30th of December, 1819, and the last on the 28th of September, 
1824, which were rapid and easy, was brought almost to the gates of 
death by enormous discharges, which commenced about five minutes 
after the birth of the foetus. I saw her lie pulseless, and as near as 
possible to dissolution in those labors. In two subsequent confine- 
ments, she took one scruple of ergot, just as the foetal head began to 
emerge. This was given to her, not for the purpose of aiding in the 
expulsion of the child, or placenta, which had never occasioned any 
embarrassment in antecedent labors; but, by constricting the womb 
permanently, to save her from those dangerous losses ; and I am 
pleased to say, that in both instances, she experienced none beyond 
the ordinary amount of effusion. I could cite very numerous examples 
of similar results. 

Sitting up too soon. — As regards the danger of sitting up soon after 
delivery there are some important suggestions for the Student that 
ought not to be here omitted. 

Certain women are met with who pass through the conflict of partu- 
rition unscathed, and who are quite as competent to the performance 
of their daily toil on the following day as the Chief's wife who so 
much excited the astonishment of Hearne on his Northern Journey. 
I have found that many of my patients, and some in the class of what 
are called the " upper ten thousand," were completely destitute of all 
symptoms of indisposition as the halest Potowattamie or Ottowa. 
Such people might get up, and I have seen very elegant women get 
up and "be about" on the third day without pretence of after indispo- 
sition. Still it is a safe rule to advise the keeping of the bed for many 
days, since to leave the bed is to go forth a la chasse after some malady. 
Hemorrhages, chill, prolapsions, and an evil train attend those impru- 



308 CONDUCT OF LABOR. — CLOT IN THE HEART. 

dent women who leave the lying-in couch too early. A rest of nine 
days is a short rest after nine months of fatigue crowned by the ex- 
hausting conflict of a labor. 

But it is not merely to the treatment of the ordinary cases that I 
designed to call the attention of the Student. My warning is directed 
against the mismanagement of those women who have lost too much 
blood in the parturition, and particularly to such as have lost a great 
quantity. 

It is well known that the coagulability of the blood is greater in 
proportion as any hemorrhage progresses — therefore a woman who has 
lost during her labor 40 or 80 ounces of blood has the rest of it more 
coagulable than it was before the flooding commenced. Again, faint- 
ing consists in the too little intensisty of the pressure of the blood in the 
brain, — and a woman just gone through a flooding experiences a sensa- 
tion of faintness from lessened vascular distension of her encephalon. 
If she suddenly assume an erect position the tension becomes instantly 
lessened in consequence of the gravitation of the blood. But — and 
this is the danger, — if she faint badly while her blood is become thin 
and highly coagulable from hemorrhage — the scarcely moving current 
partially stops in the heart, and when she comes out of the deliquium, 
if ever, she does so with a coagulum in the auricle and ventricle — 
she has got a false polypus in the cavities — and she will surely die. 

In the early part of 1844, a young and beautiful lady gave, pain- 
fully, birth to a daughter. She lost a large quantity of blood at the 
separation of the after-birth — and was pale and weak up to the third 
day. On the morning of that day her physician found her comfortable 
at 9 o'clock. The pulse was 90 per minute. The milk was begun 
to be abundant and the prognosis favorable. Half an hour after the 
Doctor had withdrawn from her apartment, he was recalled and found 
her apparently dying — the pulse at least 160 — the anxiety intense and 
the paleness mortal. 

She rallied from this lowness — but the pulse remained ever rapid, 
small and irregular until she died with the thorax full of water about 
the 20th day post puerperium. 

Upon being informed of the suddenness and the manner as well as 
the occasion of her illness, I said she had coagulated the blood in her 
heart during the deliquium, that the chordae tendinias might thresh it 
partially into shreds, and that it would terminate her existence. 

— The difficulties in the pulmonic circle connected with the presence 
of the coagulum in the right ventricle and auricle, doubtless led to the 
great hydrotheracic deposites, and the examination of the body after 



CONDUCT OF LABOR. — TAMPON. 309 

her death made manifest the truth of my diagnosis. — But, it was 
unnecessary to use the bistoury to reveal an anatomy which the reason 
discloses as well as the scalpel — what M. Serres calls Transcendental 
Anatomy goes farther and surer than the dissection. 

In the present example — a woman exhausted with flooding — but 
with a pulse at 90, rises from her bed and faints — she recovers with a 
tumultuous pulse beating 160, and continuing so nineteen days until 
her death — what else could occasion these phenomena except what the 
Transcendental Anatomy demonstrates to be a false polypus in the 
heart! 

Tampon Never. — I repeat the opinion already expressed, that the 
blood that issues from the placental suface of the womb after de- 
livery at Term, ought to be permitted to flow freely out from 
the vagina. After it is effused it is of no use to the woman. 
What is the reason that a woman does not bleed to death after the 
placenta is detached? It is not because a coagulum is formed, 
by which the effusion is arrested. She is saved by the condensa- 
tion of the uterine tissue, which is not only sufficiently diminished 
in volume to close the small orifices of the vessels on the placental 
surface, but even to close the largest sinuses that may be opened 
during the Caesarian section, or in extensive lacerations of the womb. 
I saw, in a Caesarian operation, the scalpel open the uterus imme- 
diately over the placenta — an incision large enough to permit me 
to extract the child with sufficient facility. The cut was, of course, 
through the most vascular part of the organ. I need not say, that the 
blood bubbled up from the incised surfaces very rapidly; but it wholly 
ceased to flow as soon as the placenta was removed from the womb 
so as to permit that organ to contract. The condensation of the womb 
in contracting, shut up the cut vessels as completely as if ligatures 
had been applied to them. I repeat again, that a very firm clot, 
shutting the mouth of the womb, may serve as a tampon which shall 
wholly prevent the escape of blood from the cavity, which expands as 
it continues to receive the effusion, until the womb becomes fully as 
large as at the sixth month. Such clots should be broken up, and 
removed. They are as dangerous as, but not more so than the arti- 
ficial tampon, when used after delivery at term. I have never used a 
tampon after delivery at term ; but I have seen them used, which came 
very near causing the patient to sink, by detaining the effusion within 
the cavity. The principle is false, and the practice dangerous, which 
resorts to such a mode of arresting uterine hemorrhage, at term; he 



310 CONDUCT OF LABOR. — COAGULA. 

who resorts to it, does so under the ignorant presumption that uterine- 
like chirurgical hemorrhage is to be arrested by coagulation of the 
outflowing blood. If it should be said here, that women very com- 
monly do discharge utero-morphous clots after delivery, I admit the 
fact ; but I subjoin, that but for a sufficient degree of irritability in 
such uteri, the clots would become so large as to require for their 
formation a wasteful, and even dangerous or fatal extravasation of the 
vital fluid. Strong uteri never permit them ; weaker ones allow pretty 
large ones to be formed, and very feeble wombs fill until the woman 
faints or dies. 

Turn out the Clot. — I should feel happy if I could impress upon 
the mind of the Student, in such a manner as to make it ever present 
to him when the occasion demands, that the only certain mode of ar- 
resting uterine hemorrhage is to empty the womb and cause it to con- 
tract. If a woman have alarming discharges of blood before the 
delivery of the child, let him take away the child, if he can. If she 
bleed before the after-birth is withdrawn, let him withdraw it. If she 
bleed after delivery, let him introduce his fingers into the uterus and 
break to pieces the firm coagula that he will find in it, or in the vagina, 
and then by frictions of the hypogaster, or by cold, by pressure, by 
ergot, and by all the means in his power, let him compel the womb 
to contract ; then, and not until then, will his patient be safe. 

Binder. — Case. — I attended Mrs. J. A. S., confined with her fifth 
child, in a labor that was perfectly natural, relatively to the birth of 
the child, the delivery of the placenta, and the symptoms that imme- 
diately ensued the parturient state. 

Having waited about half an hour, I took my leave of the patient 
about two o'clock in the morning, and had proceeded a good way to- 
wards my house, when I was overtaken by her husband, who entreated 
me to hasten back to the lady, as she seemed near dying. 

Upon returning to the house, I found my patient without pulse, the 
face of an excessive paleness, and the whole state expressive of the 
last degree of sinking or prostration. The idea that immediately 
became obvious was, that, she must have had a large effusion of 
blood: but upon placing the hand on the uterine region, the organ 
was found well condensed; while, upon careful examination of the 
bed, no very considerable extravasation of blood was detected. I 
found that the abdominal parietes were very remarkably flaccid ; to 
such a degree as to strike me, forcibly, as affording incompetent sup- 



CONDUCT OF LABOR. COAGULA. 311 

port to the viscera within; indeed, the contractility of the abdominal 
muscles and integuments was so very slight, that it appeared to me 
the bowels could have derived almost no support from their pressure. 

After exhibiting such restoratives as were at hand, I folded two large 
towels into squares, and placing them upon the abdomen, as com- 
presses, secured them by a bandage, which retained them in situ, and 
thus afforded such a degree of support to the contained viscera, as I 
deemed sufficient to obviate the sinking and fainting tendencies which 
always ensue from a loss of this support or pressure. I enjoined rest 
in a horizontal posture, removed the pillows from under the head, and 
when the forces of the constitution rallied there was no further alarm 
or distress. It has happened to me many times to meet with this 
syncopal state, after delivery, unaccompanied with hemorrhage, either 
internal or external ; and in all parturient persons, who are enormously 
distended, or who are prone to such faintings after delivery, I take 
the precautions suggested by the above case in good time ; and can 
safely say, that such precautions generally result in success. 

The weakening effect of a removal of pressure or support from the 
contents of the abdomen, is noticed not only in labors, but in tapping 
the abdomen for dropsy. It is always deemed necessary, in tapping 
very distended persons, to pass a broad roller round the abdomen, so as 
to constrict it in proportion as the w T ater flows off. In cases of para- 
centesis, where this precaution is not observed, the patient is very apt 
to faint, and evidently from the same cause I have mentioned, namely, 
the want of pressure on the contained organs. I had occasion, more 
than two years ago, to verify this principle in a case. A young w t o- 
man, excessively distended with ascites, was tapped ; the water 
flowed off very rapidly : in proportion as it escaped I tightened the 
bandage, and she made no complaint of faintness. In order to test 
the effect of relaxing it, I withdrew all pressure for a very short time, 
the water still flowing, and she immediately began to grow sick and 
faint; w 7 hich symptoms ceased as soon as I renewed the pressure with 
the bandage. It is w r ith the greatest confidence, both as to its neces- 
sity and efficacy, that I therefore recommend, that a bandage should 
be early placed around the abdomen of such patients as are prone to 
fainting after delivery, as the compression, all things being ready 
prepared, may be applied soon after the birth, without disturbing the 
patient. 

It is well worth the Student's while to bestow some sober thought 
upon the subject of the binder for a newly delivered woman. As a 
general precaution, it is doubtless a laudable one to bind up the 



312 CONDUCT OF LABOR. DIET. 

"weakened and exhausted abdominal cavity. But, it is questionable 
as to how long it should be used. Certainly after the first days of the 
confinement, it is not to be held necessary as a preventive of syncope 
or hemorrhage; nor has it any special usefulness beyond the doubtful 
one of restoring the woman's shape. But as to this, I think that 
Asdrubali is very correct in his assertion, that it cannot at all restore 
the figure, whose restoration depends upon the vital contraction of the 
muscular and other tissues that have been relaxed by the gestation. 
I fear that much of the too general complaint of prolapsus and retrover- 
sion of the womb among American women may be attributed to the 
use of bandages worn so tight, and so long, as to drive the recovering 
uterus to the bottom of the pelvis or even overset it backwards into 
the hollow of the sacrum. 

Diet. — The diet of a woman recently delivered, ought to be very 
light, and of easy digestion; tea, bread, gruel, vegetable jellies, and 
panada suffice, and are the safest materials during the three or four 
first days of the accouchement. Circumstances may demand a more 
liberal allowance; but, for persons who have small lochial evacua- 
tions, or who are of an excitable constitution, the simplest elements 
of nutrition only should be prescribed. For a surgical patient, 
both before and after the completion of the operation, a regimen 
is deemed of vital importance ; and yet the shock to the constitution, 
and the irritative influences of the w r ound, in severe or capital opera- 
tions, are not greater than those developed by many instances of labor : 
are not dietetic precautions equally proper, then, in both cases ? In 
addition to these considerations, it ought to be remembered that during 
the months of gestation, the fluxional determinations have been to- 
wards the uterus; but now the wave of vital fluids is marching towards 
another set of organs, and great disturbances are, many times, occa- 
sioned by this mutation of directions. The effort of the constitution 
produces fever, which commences simultaneously with the irritation 
of the mammary glands; but, happily, when those glands are enabled 
to throw off an abundant secretion, the whole constitution is relieved 
by the evacuation, and the fever suffers a crisis, as well marked as 
that of a bilious remittent or any other febrile disorder, that goes off 
by a profuse diaphoresis or diarrhoea. Let the body, then, be pre- 
pared for this fever, by a correct course of diet ; and when that crisis 
has been completed, much of the hazard of an accouchement will be 
already overpassed, and a reasonable indulgence in stronger food be- 
come safe and proper. 



CONDUCT OF LABOR. NURSING. 313 

Suckling. — The child should be put to the breast as soon as the 
mother has recovered sufficiently from her fatigue and exhaustion. 
This is a natural course — it is, therefore, the best one ; for by the act 
of sucking, the new determinations, about to arise, are invited to, and 
restrained within their proper bound : the vital wave ought to come 
hitherto, but no farther. Such a course is useful for the child which 
generally procures, from the earliest lactation, some saline fluids that 
have a favorable influence on its digestive tube; and for which ought 
not to be substituted that pernicious compound, molasses and water, 
which every child in the country is doomed to swallow, at the cost 
of a sour stomach and flatulent bowels, displayed in the almost uni- 
versally resulting symptoms of colic, green stools and vomiting. The 
antediluvian mothers had no molasses and water for their children, 
who lived, nevertheless, a thousand years. Certainly nothing can be 
more conformable to the dictates of nature, than an early application 
of the infant to the mother's breast. If we could suppose a woman 
in a state of nature, to be delivered alone, under the shade of some 
primeval forest, and unsuspected, observe her conduct, we should 
witness the instinctive movements and promptings of nature, that 
would far better guide us in the management of such affairs, than the 
crude conceptions of those, who are ever ready to boast of the excel- 
lence of art or skill, over the sure suggestions of instinct. Such a 
mother would soon be aroused from the weakness and languor that 
succeed the pangs and throes of child-birth, by the cries of her help- 
less offspring. She would take it, as soon as a little returning strength 
should permit, into her arms, and the newly-born child would proba- 
bly not nestle a moment on the maternal bosom, without finding the 
source of its future aliment : the very anatomical structure, both of 
the maternal arms and breast, and the instinctive motions of the child's 
head, would bring its lips speedily in contact with the nipple. But 
we, wiser than our great instructress, often keep the new-born child 
away from its natural resting place, and deprive it of the most appro- 
priate nutriment for two or three days, in order to eschew sore nip- 
ples, or to propitiate some other imaginary evil; while we allow the 
breast to fill almost to bursting, and actually to inflame from disten- 
sion, before we admit that preparation to be complete, which our pre- 
sumptuous interference, in this manner, vitiates and troubles. The 
child ought to be put to the breast as soon as the mother is strong 
enough to take it. 

Medicine. — It is a good custom to give an aperient medicine on 



314 CONDUCT OF LABOR. LOCHIA. 

the third day, or about seventy hours after delivery ; while, in most 
cases, it is safest to defer the administration, at least up to this period. 
The perturbations of vital action in the abdominal viscera, occasioned 
by medicines administered too early, are observed to result in symp- 
toms of congestion, and of peritoneal fever, in not a few instances, 
particularly where an epidemic tendency to the latter malady exists. 

It should be well understood in the lying-in apartment, that no 
medicines are to be given to the mother or the child, without the 
sanction or advice of the medical attendant. In our part of the country, 
it is exceedingly common for the nurse to take upon herself the func- 
tion of prescriber, and to administer a dose of severe cathartic medi- 
cine, upon her own responsibility; which, however great and important 
she may deem it, remains, after all, with the physician. He it is who 
bears the burthen, and undergoes all the trouble and anxiety and 
responsibility of the management. He ought, therefore, always to 
direct that no interference with his rights should be suffered to take 
place. There are many reasons why he should be the sole director 
of the case ; for it is not a matter of indifference what particular article 
is selected, any more than it is of little consequence at what moment 
the medicine (if any) be administered. 

Castor oil is the article in most request, for this period of the con- 
finement ; and in a dose of half an ounce, operates sufficiently well. 
Where the castor oil is particularly disagreeable, a proper quantity of 
magnesia and rhubarb ; of infusion of senna ; of Epsom salts ; of Seid- 
litz powders, may be substituted; but, in general, the oil is to be pre- 
ferred, because of the great certainty and moderation with which it 
operates on the bowels. 

Lochia. — The lochial discharges grow gradually less abundant, 
and of a paler color. The tone of the womb itself must determine, in 
a great measure, the duration and amount of the discharge. It dis- 
appears in the third week, and sometimes, earlier. Not a few women 
continue to have a show in the fifth week; and, in fact, the Jewish 
women had their purification at the fortieth day, which probably might 
be founded on observations as well suited to the inhabitants of this 
country as to those of the Holy Land. 

Sitting up. — A woman who has gone through the fatigues of preg- 
nancy and the pangs of labor, is one much exhausted, and requiring 
a long repose. 

The constitution of society will not permit us, in the majority of 



CONDUCT OF LABOR. ANESTHESIA. 315 

cases, to insist upon a sufficiently long rest after labor; for the wives 
of the poor and the thrifty will, or must rise from the lying-in bed 
sooner than those ought, who have a due respect for either health or 
beauty. 

To rise before the fifth day is to go forth to seek disease — which is 
less apt to attack an individual who is protected by warm coverings 
from the weatherly influences, and by recumbency from the circulatory 
and nervous influences that tend to disorder the health. 

If a woman will rest long after her labor she will recover more per- 
fectly. If she leaves her bed too soon, she will recover less perfectly, 
and thus not only suffer the future disadvantages connected with bad 
health, but she will lose her bloom earlier in life. 

It appears to me advisable to let her set up only on the tenth day, 
and to ride out not earlier than the twenty-first day, in summer, and at 
the end of the month in winter. She should not be held to be clean 
until the lapse of the fortieth day. 

Etherization. — In speaking of the various points in the Conduct 
of a labor, I cannot well eschew to say something upon the employ- 
ment of those anaesthetic agents, whose recent irruption into the 
domain of Medicine and Surgery has been so sudden, violent, and 
overbearing. 

To avoid altogether any notice of these agents, w T ould have been 
more consonant with my taste as well as with my views of medical 
duty; but as I feel that those w T ho may please to have this book will 
surely expect to find a record of my opinions on anaesthesia as an ob- 
stetric resource, I feel constrained to overcome my reluctance to say 
anything concerning it. 

In Philadelphia, the use of ether and chloroform in Surgery and Mid- 
wifery has made no real progress, notwithstanding the very numerous 
reports upon the benefits derived from those agents in Europe and 
in parts of the United States. A few of our surgeons in this metropolis 
have applied the ether inhalation in their surgical cases — and some 
persons in labor have likewise been rendered insensible to their pain 
by breathing the vapor of chloroform or ether. I am not able to say 
in how many instances this recourse has been had here; but I should 
suppose, that not fewer than forty to sixty women have been subjected 
to it on account of labor ; and I believe the practice does not become 
more common and general in our community ; and that fewer women 
in labor will have been etherized in the last than in the first six months 
of 1848. 



316 ANESTHESIA IN MIDWIFERY. 

I do not feel inclined at all to deny that there may be instances of 
severe suffering for women in labor, that ought to be mitigated or 
even wholly obviated by casting the woman into the profound anaes- 
thesia of chloroformization. But what I do desire to say is this, viz: 
— that having carefully studied the reports upon etherization and 
chloroformization, whether those of this country or those produced in 
Europe, I remain as yet unconvinced — either of the necessity for the 
method, or of its propriety. 

1st. As to its necessity in ordinary cases of parturition. The ave- 
rage duration of labor is four hours, and I have shown at page 252 
that the number of labor pains is about fifty; and that they last, each 
about thirty seconds, so that the parturient woman really suffers from 
labor pains about fifteen or sixteen minutes and no more — and these 
sixteen minutes are distributed among the four hours of a labor of mean 
duration. 

It has never been pretended that the motive for the anaesthetic practice 
has any connection with the other pains of women in labor, but only 
with the suffering from contraction or labor-pains ; for, though we may 
well suppose, that women suffer from painful sensations independent 
of those arising from the actually contracting womb, yet we find 
them in general, easy, complacent, and but too happy when the pain 
is off. Hence the ether is exhibited for the pain and for no other 
motive. 

I contend, that it is to an exaggerated notion of the nature of labor- 
pains we owe the introduction of ether into our art; for if the mean 
of labor-pain be only fifteen minutes in all, there can be no necessity 
in the average of cases for its exhibition. I should find the objection 
to it less and the inducement greater, were the fifteen minutes of pain 
to be always fifteen consecutive minutes. When they are distributed 
through two hundred and forty minutes, or four hours, I look upon 
the exhibition as unnecessary and uncalled for. 

2d. The representations that have been made by the friends of the 
anaesthesia, of the harrowing distress endured by women in childbirth, 
do not consist with the general state of facts in the case ; and it is 
quite as true, that a lying-in room is, for the most of the scene, a 
scene of cheerfulness and gaiety, instead of the shrieks and anguish 
and despair which have been so forcibly portrayed. 

Few women lose their health or their lives in labor, and the dread 
of future sufferings is insufficient to prevent the increase of the family. 
As to the necessity of the Letheon practice, the birth of the past 
myriads of the race shows that it is not necessary. 



ANESTHESIA IN MIDWIFERY. 317 

The propriety of resorting to the use of chloroform and ether as 
means of obviating the pain and hazards of labor, is a question to be 
settled by an estimate of the safeness as well as necessity of it. 
It were well, before making up his mind upon this point, were the 
Student to make himself well aware that the encephalon is a compound 
organ, or a compound bulbous nervous mass ; part of which (the Hemi- 
spheres) are devoted to the offices of intellection; part, the cerebellum, 
to the duty of coordinating or regulating the movement, or the force 
which is generated perhaps by the whole nervous mass; a part, the 
tuberculaquadrigemina, to the faculty of seeing or vision; and a part, 
the medulla oblongata, to the important office of governing or giving 
force to the act of respiration. Thus we have the brain of intellection 
and those of coordination of force, of vision, and of respiration. They 
might be denominated the thinking, regulating, seeing, and breathing 
bulbs of the nervous mass. 

Now, it appears from many numerous reports contained in the 
Comptes Rendus of the French Institute, and from papers in various 
journals containing accounts of experiments made both in them and in 
animals, that to breathe for a few minutes the vapor of ether, or of 
chloroform and various volatile liquids, is to cast the subject into an 
insensibility called anaesthesia, so profound that the cautery, whether 
actual or potential, the bistoury, the ligation, or the forceps are equally 
incapable of exciting a sense of pain. Nay, more, that the patient 
in some instances, looks upon the incision of his flesh without feeling 
the knife. 

Very soon after ceasing to inhale the vapor the insensibility disap- 
pears, and the individual upon recovering the use of his faculties, is 
with difficulty persuaded to admit that he has been subjected to a 
severe operation, and the mother is incredulous as to her having borne 
a child during her sleep. Such are the facts. The Student ought to 
know them. Half an ounce to an ounce of ether poured upon a 
sponge, and held to the mouth and nose, or a drachm to two or three 
drachms of chloroform administered in the same way, bring on the 
insensibility in from three to ten minutes, less or more. The insen- 
sibility once produced may be maintained according to the pleasure 
of the physician, by repeating the application of the moistened sponge 
from time to time upon any manifest signs of returning consciousness. 

The statements show that the power of these ansesthetics is capable of 
abolishing the sensibility without greatly interfering with the motor 
power of the subject — or it may abolish the motor power and allow 
the sensitive power to be acute as in health. The inhalation may 



318 ANESTHESIA IN MIDWIFERY. 

produce anaesthesia of the thinking brain, yet leave the co-ordinating, 
breathing and seeing brains intact — or it may put a temporary end to 
the power of the cerebellum and tubercula quadrigemina without influ- 
encing the other parts of the encephalon. In short there is no ascer- 
tained law of progression in the activity or power of the anaesthetic 
agent, and no man knows, when he begins to administer the vapor, 
upon what part of the brain it will proceed to exert its benumbing 
power. M. Flourens has shown, that all the other parts of the brain 
may be safely suspended of their forces, provided the medulla oblongata 
be unattacked by the agent, and that as long as the medulla oblongata 
retains its energy it is capable of recalling the other bulbs to life and 
activity through its own force, provided the further inhalation of the 
letheon is arrested. Hence he calls the medulla oblongata the vital 
tie, (le nceud vital,) since it binds the rest of the encephala with its 
" silver cord." 

Now I have to suggest to the Student the propriety of asking what 
would be his feelings provided in any such case this silver cord should be 
loosened : and I ask him whether, if the anaesthesia should proceed at 
first, or secondarily, to attack and overthrow the power of the medulla 
oblongata, his patient would not be instantly deprived of life! For if 
to breathe is to live, to be deprived of the uses of the medulla ob- 
longata is to die — since on that nceud vital depends the whole business 
of the oxygenation of the body. 

Many, and but too many examples of the power of these tremen- 
dous agents to overthrow, almost instantly, the force resident in the 
medulla oblongata are spread upon the records of medicine in the last 
two years. I do not well understand how those persons can recover 
their composure or their complacency who, by an unnecessary and 
inappropriate resort to so dangerous a process, have seen the victims 
of this extraordinary power struck lifeless before their eyes. 

It behooves not me to enter into the lists with the surgeons who cast 
their patients into the deep insensibility of etherization before perform- 
ing their operations — suum cuique tribuito is a proper law for me in 
this place. But I cannot avoid the feeling of astonishment which 
seizes upon me w 7 hen I read the details of cases of midwifery that 
have been treated during the profound Drunkenness of etherization. 
To be insensible from whisky, and gin, and brandy, and wine, and 
beer, and ether, and chloroform, is to be what in the world is called 
Dead-drunk. No reasoning — no argumentation is strong enough to 
point out the ninth part of a hair's discrimination between them-- 
except that the volatility of one of the agents or its diffusibility as a 



ANAESTHESIA IN MIDWIFERY. 319 

stimulant narcotic, enables it sooner to produce its intoxicating effect, 
which is sooner recovered from. 

I showed in the first part of this section why I deemed the use 
of etherization in Midwifery unnecessary; in the second part I 
have endeavored to show why it is improper. I have by no means 
said what I am inclined to say as to the doubtful nature of any 
processes, that the physician sets up, to contravene the operation of 
those natural and physiological forces that the Divinity has ordained us 
to enjoy or to suffer. The question is often propounded as to the Benefi- 
cence that ordained woman to the sorrow and pain of them that travail 
in childbirth. It ought to be taken for granted, without any, the least, 
disposition to what is called canting, that some economical connection 
exists betwixt the power and the pain of labors. While, therefore, 
we may assume the privilege to control, check and diminish the pains 
of labor whenever they become so great as to be properly deemed 
pathological, I deny that we have the professional right, in order to 
prevent or obviate them, to place the lives of women on the hazard 
of that progress of anaesthesia, whose laws are not, and probably can 
never be ascertained so as to be foreknown. Notwithstanding I have 
expressed the above opinions in regard to etherization in Midwifery, 
which might suffice to expose my sentiments upon that topic, still my 
respect for eminent brethren who think differently, calls upon me to 
acknowledge their equal rights, and probably superior claims to the 
confidence of the Student. Professor Simpson, of the University of 
Edinburgh, it is well known, is among the most distinguished and able 
advocates of the anaesthesia in our art. I will not, therefore, refrain 
from laying before the reader the following letter from that eminent 
gentleman, with my answer to his communication. 

Letter from Professor Simpson. 

Edinburgh, January 23d, 1848. 

Dear Sir: — By private letters from America, brought by the last 
steamer, I hear that in most of the cities of the Union, your chemists 
had failed in preparing proper chloroform; and that consequently, 
most experiments tried with it had been unsuccessful. In Great 
Britain, and on the Continent of Europe, chloroform has everywhere 
entirely, or nearly entirely, superseded the use of sulphuric ether, as 
an anaesthetic agent. The want of success which has attended its 
employment in America is, perhaps, owing in a great measure to an 
error of my ow'n, viz: to my not stating in my original account of 



320 ANESTHESIA IN MIDWIFERY. 

it, the proper method of purifying it. This and other omissions were 
owing to the haste with which my first paper was drawn up. 

I will feel, therefore, deeply obliged by your taking any measures 
that you may deem fit, to circulate amongst American medical men 
the formula which I inclose for the preparation of chloroform. It is 
the formula used by Messrs. Duncan and Flockhart, our Edinburgh 
druggists, who have already manufactured enormous quantities of it. 
They always now are able to produce it as heavy as 1500 in specific 
gravity. Their first distillation of it is made in two large wooden 
barrels, with a third similar barrel as a receiver. They throw hot 
steam into the two first barrels, which serves to afford both sufficient 
heat and water for the process. They employ sixty pounds of chlo- 
ride of lime at each distillation, and have been able to manufacture 
three hundred ounces of chloroform a day. Each ounce of the chlo- 
ride yields, in the long run, about half an ounce of chloroform : con- 
sequently, to obtain three hundred ounces, (as above,) about six 
hundred ounces of bleaching powder are required. At first they could 
only make ten or twenty ounces per diem, then they rose to sixty, and 
latterly, enlarging their barrels, they can make, as I have said, three 
hundred ounces in the twenty-four hours. 

Various other chemical houses in Edinburgh, Liverpool, Glasgow, 
York, London, &c, are busy manufacturing it in great quantities. 
They keep their formulas as secrets. But none of them make so good 
an article as Duncan & Flockhart, whose formula I append. 

The statements which I have already made, may show you to what 
an extent the chloroform is used in this country ; and our chemists 
tell me that the demand for it steadily increases with them. 

In Surgery its use is quite general, for operations, painful diag- 
nosis, &c. My friend, Dr. Andrew Wood, has just been telling me 
of a beautiful application of it. A boy fell from a height, and se- 
verely injured his thigh. It was so painful that he shrieked when 
Dr. Wood tried to handle the limb, and would not allow of a proper 
examination. Dr. W. immediately chloroformed him — at once ascer- 
tained that the femur was fractured — kept him ansesthetic till he sent 
for his splints — and did not allow his patient to awake till his limb 
was all properly set, bandaged, and adjusted. 

In Medicine its effects are being extensively tried as an anodyne, 
an anaesthetic, a diffusible stimulant, &c. Its antispasmodic powers 
in colic, asthma, &c. are everywhere recognized. 
' In Midwifery most, or all of my brethren in Edinburgh employ 
it constantly. The ladies themselves insist on not being doomed to 



ANAESTHESIA IN MIDWIFERY. 321 

suffer, when suffering is so totally unnecessary. In London, Dublin, 
&c, it every day gains converts to its obstetric employment, and I 
have no doubt that those who most bitterly oppose it now, will be 
yet, in ten or twenty years hence, amazed at their own professional 
cruelty. They allow their medical prejudices to smother and over- 
rule the common dictates of their profession, and of humanity. 

No accidents have as yet happened under its use, though several 
hundred thousand must have already been under the influence of chlo- 
roform. Its use here has been a common amusement in drawing- 
room parties, for the last two or three months. 

I never now apply it with anything but a silk handkerchief. In 
surgical cases and operations, the quantity given is not in general 
measured. We all judge more by the effects than the quantity. 
Generally, I believe, w T e pour two or three drachms on the handker- 
chief at once, and more in a minute, if no sufficient effect is produced, 
and we stop when sonorous respiration begins. Not unfrequently 
spasms, rigidity, &c, come on, but they disappear as the effect in- 
creases, and none of us care for them any more than for hysteric 
symptoms ; nor do they leave any bad effect. But the mere appear- 
ance of them is enough to terrify a beginner. 

I shall be glad to hear how the cause of anaesthesia gets on among 
you, and I remain with great respect, Very faithfully yours, 

J. Y. SIMPSON. 

To Professor Meigs. 



The following is the formula for Chloroform, communicated by Pro- 
fessor Simpson : 

Take of Chloride of Lime in powder, 4 pounds. 

Water, .... 12 a 
Rectified Spirit, . . 12 fluidounces. 

"Dumas." 
The chloride of lime and water being first well mixed together, the 
spirit is added. Heat is then applied to the still, (which ought not to 
be more than a third full,) but as soon as the upper part of the still 
becomes warm, the heat is withdrawn, and the action allowed to go 
on of itself. In a short time the distillation commences, and when- 
ever it begins to go on slowly, the heat is again applied. The fluid 
which passes over, separates into two layers, the lower of which is 
Chloroform. This, after having been separated from the weak spirit 
forming the upper layer, is purified by being mixed with half its mea- 
21 



322 ANESTHESIA IN MIDWIFERY. 

sure of strong sulphuric acid, added gradually. The mixture, when 
cool, is poured into a leaden retort, and distilled from as much car- 
bonate of baryta by weight, as there is of sulphuric acid by mea- 
sure. The product should be allowed to stand over quicklime for 
a day or two, and repeatedly shaken, and then re-distilled from the 
lime. 



Reply to Prof. Simpson's Letter. 

Philadelphia, Feb. ISth, 1848. 

Dear Sir: — I have to acknowledge the favor of your letter of Jan. 
23d, which I received yesterday. 

The chemists in this country have produced very perfect chloroform, 
of the specific gravity of 1450, as I am informed, and which is much 
employed in dentistry operations, and to a considerable extent also in 
surgery. 

I presume you will, ere this date, have received copies of Prof. 
Warren's pamphlet on " Etherization," which may inform you, very 
fully, as to the use of the anaesthetic agent in the Massachusetts 
General Hospital, and in Boston. That eminent gentleman is more 
reserved as to the obstetric employment of the agent ; much more so, 
I understand, than either Dr. Channing, Dr. Homans, and other prac- 
titioners, who make use of it very commonly. 

In New York, as I learn, the surgical application of chloroform is 
common, while its obstetrical use has not as yet acquired a general 
vogue. 

In Philadelphia, we have the Pennsylvania Hospital, with more than 
two hundred beds. A very considerable amount of surgical practice, 
which renders that house a favorite clinical study for medical students 
of the United States, has not, as yet, furnished a single example of 
the exhibition of chloroform or ether as anaesthetic agents. The Sur- 
gical Staff of the Institution have not become convinced of the pro- 
priety of such a recourse in the operations performed there. 

In the Jefferson College, to which I am attached, as Professor of 
Midwifery, etc., there is a medical and Surgical Clinic held on the 
Wednesday and Saturday of each week. The resort of surgical cases 
there is very great, and a Clinical day rarely passes without some sur- 
gical operations before the classes. The clinical professors, (in sur- 
gery,) Drs. Mutter and Pancoast, almost invariably employ the chlo- 
roform, and the successful exhibition of the article has entirely 
confirmed them in their opinion of its great value. Some of the ope- 



ANESTHESIA IN MIDWIFERY. 323 

rations have been of the gravest character, and no serious event has 
occurred to check the career of the remedy. 

As to its employment in Midwifery here, notwithstanding a few 
cases have been mentioned and reported, I think it has not yet begun 
to find favor with accoucheurs. 

I have not exhibited it in any case ; nor do I, at present, know of 
any intention in that way, entertained by the leading practitioners of 
obstetrical medicine and surgery, in this city. I have not yielded to 
several solicitations as to its exhibition, addressed to me by my pa- 
tients in labor. 

As to the extension of the anaesthesia in the Southern and Western 
States, I am not at present enabled to give you information. I be- 
lieve the practice is slowly gaining converts, and that it will become 
more and more common ere long. 

You may perhaps feel surprised at this admission on my part, see- 
ing that I am still a recusant ; and I ought, therefore, to be ailowed 
to explain myself, lest I should continue to appear unreasonable in 
your eyes. 

Having carefully read the Comptes Rendus of the Royal Academy 
of Medicine of Paris, which contained full reports of the copious 
discussions on the question of the Letheon, a few months since, and 
having also seen the English and American Reports in the Journals, 
and particularly having read your own pamphlet of " Remarks," 
&c, I may not properly be accused of ignorance of the power, 
effects, or motives, in relation to chloroformization in surgery, or ob- 
stetricy. The copy of your own pamphlet, for which I now beg 
leave to thank you, would necessarily have put me au niveau on the 
subject. 

Not being myself engaged in the practice of surgery, proper, I pre- 
fer to avoid any expression of opinion as to the propriety of the prac- 
tice; and I do this upon the principle, suum cuique tribuito. It 
would be an impertinence in me, were I to interfere with the conduct 
of the surgeons. 

But, in midwifery, to which a long and extensive practice has 
enured me, and rendered me a familiar, dispassionate witness of its 
various forms and phenomena, I am less liable to misconceptions. 
And here allow me to say, I have been accustomed to look upon the 
sensation of pain in labor as a physiological relative of the power, 
or force ; and notwithstanding I have seen so many women in the 
throes of labor, I have always regarded a labor-pain as a most de- 
sirable, salutary, and conservative manifestation of life-force. I have 



324 ANAESTHESIA IN MIDWIFERY. 

found that women, provided they were sustained by cheering counsel 
and promises, and carefully freed from the distressing element of 
terror, could in general be made to endure without great complaint, 
those labor-pains which the friends of the anaesthesia desire so ear- 
nestly to abolish and nullify for all the fair daughters of Eve. 

Perhaps, dear sir, I am cruel in taking so dispassionate a view of 
the case ; and it is even possible that I may make one of the number 
of those " amazed" converts of whom you speak in your worthy 
letter to me. But, for the present, regarding the pain of a Natural 
labor as a state not, by all possible means, and always, to be es- 
chewed and obviated, I cannot bring myself to the conviction that of 
the two, whether labor-pain or insensibility, insensibility is to be pre- 
ferred. 

If I could believe that chloroformal insensibility is sleep indeed, 
the most considerable of my objections would vanish. Chloroform is 
not a soporific ; and I see in the anaesthesia it superinduces, a state of 
the nervous system, in no wise differing from the anaesthetic results of 
alcoholic potations, save in the suddenness and transitiveness of its 
influence. 

I freely admit, for I know it, that many thousands of persons are 
daily subjected to its power. Yet I feel that no law of succession of 
its action on the several distinct parts of the brain has been, or can 
be hereafter ascertained, seeing that the succession is contingent. 
Many grave objections would perhaps vanish, could the law of the 
succession of influences on the parts of the brain be clearly made 
out, and its provisions insured. There are, indubitably, certain cases 
in which the intellectual hemispheres are totally hebetized, and de- 
prived of power by it, while the co-ordinating lobes remain perfectly 
unaffected. In others, the motor cords of the cerebro-spinal nerves 
are deprived of power, whilst the sensitive cords enjoy a full activity, 
and vice versa. 

In some instances, the seeing brain enables the patient to look upon 
the application of a cautery that he does not feel, while it sears him, 
or of a bistoury whose edge gives him no pain. In others, the influ- 
ence of the agent upon the sources of the pneumogastric and phrenic 
nerves is dangerously, or at least alarmingly, made manifest by modi- 
fications of the respiratory force. It appears to me, therefore, quite 
certain, that there is no known law of succession of the ether-influ- 
ences on the several parts of the brain. It is known that the con- 
tinued aspiration of the vapor brings at last, the medulla oblongata 
fully under its anaesthetic power, and the consequent cessation of re- 



ANAESTHESIA IN MIDWIFERY. 325 

spiration, which determines the cessation of the oxygenation of the 
blood, and thereby of the brain, is death. M. Flourens' experiments, 
and others, especially those by the younger Mr. Wakley, of the Lan- 
cet, prove very conclusively that the aspiration of ether or chloroform, 
continued but a little longer than the period required for hebetizing 
the hemispheres, the cerebellum, the tubercula quadrigemina, and the 
cord, overthrows the medulla oblongata, and produces thereby sudden 
death. I fully believe with M. Flourens, that the medulla oblongata 
is the nceud vital, and that, though later brought under the power of 
chloroformization, it is always reducible under it. Hence I fear that 
in all cases of chloroformal anaesthesia, there remains but one irrevo- 
cable step more to the grave. 

I readily hear, before your voice can reach me across the Atlantic, 
the triumphant reply that an hundred thousand have taken it with- 
out accident! I am a witness that it is attended with alarming acci- 
dents, however rarely. But should I exhibit the remedy for pain to 
a thousand patients in labor, merely to prevent the physiological pain, 
and for no other motive — and if I should in consequence destroy only 
one of them, I should feel disposed to clothe me in sackcloth, and 
cast ashes on my head for the remainder of my days. What suffi- 
cient motive have I to risk the life or the death of one in a thousand, 
in a questionable attempt to abrogate one of the general conditions of 
man? 

As to the uses of chloroform in the medical or therapeutical treat- 
ment of pain, the question changes. There is no reasonable therapeia 
of health. Hygienical processes are good and valid. The sick 
need a physician, not they that are well. To be in natural labor, is 
the culminating point of the female somatic forces. There is, in 
natural labor, no element of disease — and, therefore, the good old 
writers have said nothing truer nor wiser than their old saying, that 
"a meddlesome midwifery is bad." Is chloroformization meddle- 
some ? 

Your countryman, old Thomas Rainold, in " the Woman's Booke, 
or The byrthe of Mankynde," at fol. LIII., says, " Very many be the 
perilles, daungers, and thronges, which chaunce to women in theyr 
labor." These are the cases requiring our therapeutical and chirur- 
gical intervention. You will, my dear sir, think me a hopeless recu- 
sant, if I decline the anaesthesia here also. I pray you, therefore, 
allow me to state my reasons for such recusancy. 

If I were amputating a limb, or extirpating a tumor, I should see 
all the steps of my incisions, ligations, &c. But if I apply my for- 



326 



ANESTHESIA IN MIDWIFERY. 



ceps in a right occipito-posterior position, (fourth of Baudelocque,) I 
know that I thrust the blade of the male branch far upwards betwixt 
the face of the child and the upper third of the vagina, which, in this 
case, is already greatly expanded, and that the extremity of the blade 
is separated from the peritoneum only by the mucous and condensed 
cellular coat of the tube. Now, no man can absolutely know the pre- 
cise degree of inclination his patient will give to the plane of her 
superior strait, while in pain ; an inclination to be modified by every 
movement of her body and limbs. Under such absolute uncertainty, 
the best guide of the accoucheur is the reply of the patient to his 
interrogatory, "Does it hurt you?" The patient's reply, "Yes," or 
"No," is worth a thousand dogmas and precepts, as to planes and 
axes, and curves of Carus. I cannot, therefore, deem myself justi- 
fied in casting away my safest and most trustworthy diagnosis, for the 
questionable equivalent of ten minutes' exemption from a pain, which, 
even in this case, is a physiological pain. 

Having thus, in my own defence, and not as attacking your opin- 
ion, set forth the motives that have hitherto served to restrain me from 
the administration of chloroform, I desist from giving you any farther 
trouble in this line of thought. I have, sir, a far more pleasing duty 
to perform, in saying that your name is as well known, perhaps, in 
America as in your native land, and to congratulate you on the ex- 
tension of your fame. I had the pleasure to read your interesting 
letter to my class, consisting of several hundred young gentlemen, 
who listened to your words with the same respect they would have 
paid to you, had they been pronounced by your own lips. They will 
disperse themselves in a few days hence, over all the States of the 
Union, and thus will have it in their power to report the latest dates 
of your opinions as to chloroform. I shall also allow it to be pub- 
lished on the first proximo, in a medical journal of extensive circu- 
lation. You will herein perceive the readiness with which I assist in 
disseminating your views. It is not without regret that I find myself 
opposed to your opinions in the case. That difference ought not, 
however, in the least degree to affect those sentiments of respectful 
consideration and real esteem with which I am, dear sir, very faith- 
fully, your obedient servant, CH. D. MEIGS. 

PflOFESSOR SlMPSOS, &c. 



FACE PRESENTATIONS. 



327 



CHAPTER XI . 



FACE PRESENTATIONS. 



73. 



In cases in which the usual dip of the occipitofrontal diameter fails 
to take place, but, on the contrary, is reversed, so as to allow the chin 
to depart far from the breast, the head may be actually turned over 
backwards, permitting the child's face to fall down into the pelvis. 

In face presentations, as deline- 
ated in Fig. 73, annexed, the chin 
is on one side, and the top of the 
forehead upon the other side of the 
pelvis. The face seems to be looking 
directly downwards into the exca- 
vation of the lower basin. This 
could not be the case without com- 
plete departure of the chin from 
the breast, {see the figure,) and an 
absolute overset of the head back- 
wards, as in a person who should be 
looking upwards at an object di- 
rectly overhead. 

These are what are denominated 
Face Presentations : a sort of labors that are thought less unnatural 
and dangerous, now, than in former times. I am clearly of opinion 
that face cases may w T ell be included among the natural labors, except 
where some failure in the powers of the woman should cause us to 
convert them into preternatural ones, obliging us to turn and deliver by 
the feet ; to restore the vertex by some serious operation; or to extract 
with the forceps, or other instrument. 

The foetal head being an oval, five inches long, from the vertex to the 
chin, and more than three and a half inches wide at the widest part, it 
ought to make no difference, as far as the mere head is concerned, 
whether the chin or the vertex advances first in labor, because, in either 




328 FACE PRESENTATIONS. 

case, the same circumferences of the head are presented to the planes 
through which they are to be transmitted. The foramen magnum of 
the occipital bone being nearly equidistant from the vertex and chin, 
and situated on one side of the oval, the peculiar difficulties and 
hazards of these labors are attributable, rather to the nature of the 
articulation by which the neck and head are conjoined, than to the 
form of the head itself, when advancing with the face downwards. 
The nature of this articulation is such, that extension of the head 
cannot take place so well as flexion : hence the requisite dip of the 
occipitofrontal diameter is not effected without difficulty, and the con- 
sumption of much time. 

Let the reader figure to himself the state of the spinal column of a 
child, urged on in labor by powerful uterine contractions, directed 
to its expulsion with the face in advance. The inferior-posterior part 
of the head is pressed against the back of the neck, or betwixt the 
scapulae, which could not be the case without bending the cervical 
spine backwards, like a bow, while the dorsal and lumbar vertebrae- 
are curved in the opposite direction, causing thus a double antero- 
posterior curve, on which, in consequence of the elasticity of the two 
arches, much of the expulsive force is vainly expended; so that, 
though the power may be as great as in a common labor, it produces 
much less effect than in a common labor; a great part of every pain 
being occupied in reproducing the greatest amount of curvature; for 
the elasticity of the two curves is such that they are straightened as 
soon as the pain subsides, at least in some measure, while the rest of 
the pain is used in pushing the face onwards. 

A child in utero is in a state of universal flexion, as I have already 
remarked. It cannot be in extension, as supposed by the old authors, 
whose rude cuts accompanying their crude descriptions of labors, are 
calculated to excite a smile of pity in any modern obstetrician. In 
this state of flexion, the chin approaches or even touches the breast. 
Such a flexion in a head labor, always gives us a vertex position. 
But if the chin, instead of approaching, depart from the breast, 
there is a tendency towards the face presentation. Let the Student 
consider that when the chin departs from the breast, it does so by 
slow degrees, and not suddenly, nor wholly, at once. Hence he 
should, in face presentations, whose whole progress he has opportunity 
to supervise, expect to touch at first the top of the forehead as the 
lowest point; or presenting point. As the labor goes on, the head 
continues to turn over more and more completely, until it is at last, 



FACE PRESENTATIONS. 



329 



Fig. 74. 




quite overset backwards ; as may be seen in the annexed drawing, in 
which, in addition to a face presen- 
tation, there is a prolapsion of the 
left foot. If, in such a labor as this, 
the foot were thrust back into the 
womb during the absence of a pain, 
w r e should have a very bad case of 
face labor, with the chin to the sa- 
crum, and the forehead to the pubis. 

When the face presents, the face 
does not enter the excavation 
with the fronto-mental diameter 
parallel to the plane of the strait. 
On the contrary, the frontal extremity 

of that line is lowest at first, but the mental extremity of it comes at 
length to be lowest at least as regards the successive planes through 
which it passes in the lower part of the pelvis, as may be seen on re- 
ference to the neat figure which is annexed. 

The direction taken by the 
face, as it proceeds, in such a g ' 

labor, is worthy of the closest 
attention of the practitioner. 
Should the chin enter the supe- 
rior strait near to the acetabulum, 
it will afterwards rotate towards 
the arch of the pubis, and, es- 
caping under that arch, will rise 
upwards over the pudendum, so 
as to allow the under aspect of 
the chin and the throat to be 
applied to the arch, and to the 
front of the symphysis, while 
the remainder of the head is 

evolving itself from the os externum. In such a birth the part that 
first emerges is the chin;, then the mouth, the nose, the forehead, the 
crown ; and, last of all, the vertex, which escapes over the fourchette, 
whereupon the flexion of the head immediately becomes complete 
again. 

This is the most favorable direction for the face to take, and it will 
generally be found that a well-formed pelvis is capable of transmitting 
a child of moderate size, almost as speedily and safely, in such a 




330 



FACE PRESENTATIONS. 



labor, as if it were a vertex presentation. Let it be remembered that 
the symphysis of the pubis is only one inch and a half long, and of 
course, if the chin should escape under the arch, the neck is so long 
that the throat can apply itself against the inside of the symphysis, 
allowing the chin, nay the whole head to be born, before any part of 
the thorax of the infant begins to plunge into the excavation. 

Figure 76 may serve to show how the chin, in a favorable case, 
comes at last to the symphysis pubis, slides down behind it, and at 
length begins to emerge underneath the crown of the pubal arch. 
Look at the figure, reflect that the occipito-mental diameter is five 
inches, and the pelvis only four and a half; and that as soon as the 
chin begins to come forward under the arch the five inch mento-occi- 
pital diameter is coming with its mental extremity out beneath the 
arch. 



Fig. 76. 



Fig. 77. 





The next figure (Fig. 77), shows how the chin rises upwards in 
front of the pubis as soon as it begins to escape beyond the arch, and 
thus allows the head to roll out of the excavation. The three outline 
heads show the three successive positions of the cranium after the chin 
has once come under the arch. 

A very contrary state of things from the foregoing obtains, where 
the chin, instead of revolving towards the front, turns towards the back 
part of the pelvis. Here the forehead must appear first ; then the 
nose; next the mouth; and lastly, the chin escaping from the edge 
of the perineum, retreats towards the point of the coccyx, allowing 
the crown of the head to pass out under the arch; and finally, the 
vertex emerges, which concludes the delivery of the head. I say that 
the forehead appears first, not that it is born first, for the part 



FACE PRESENTATIONS. 331 

first born is the chin. When the chin has escaped, and begun to 
retreat behind the perineum, the mouth becomes delivered, then the 
nose*^nd eyes, top of the forehead, crown, and lastly the vertex. This 
must be the case, considering that the occipito-mental diameter is 
fully five inches long, and that there is no antero-posterior, oblique, or 
transverse line of such length in any part of the lower excavation. It is 
impossible then to see-saw a diameter of more than five inches within 
the excavation. Therefore, if the mental extremity of the occipito- 
mental diameter descends first, it must escape first, and the occipital 
extremity last. But, while the chin is sweeping, slowly and painfully, 
down the curve of the sacrum, and especially, when it is got so low 
as the edge of the perineum, the breast of the child is entering the 
pelvis, where the space it should occupy is already taken up by the 
perpendicular diameter of the head. Imagine the enormous exten- 
sion of the os externum, required for the exit of the child, in such a 
case! 

Figure 78 shows the difficulty that is produced by a rotation of 
the chin backwards, in so clear a light, that I hope it may greatly 
assist in teaching the young Student how extremely important a mat- 
ter it is to give all possible aid and assistance to nature, in her at- 
tempts to turn it towards the front of the pelvis. 

The cause of face presentations is not perfectly well understood ; 
it is, however, probable, that they are more commonly occasioned by 
an obliquity of the womb than by any other cause. For example, 
let the womb, at the onset of labor, be so oblique as to throw its fun- 
dus far down to the left side, the child presenting by the head, and 
the vertex to the right side of the pelvis: the direction of the expul- 
sive force operating on the infant, will propel its head against the edge 
or brim of the pelvis, and either cause the head to glance upwards 
into the iliac fossa, so as to let the shoulder fall into the opening, or it 
will be turned over, so as to let the face fall into the opening, and 
thus produce a face presentation, in which the chin is near to the left 
acetabulum, and the forehead to the right sacro-iliac junction. It is 
easy to set this in a clear light, especially if it be accompanied with 
demonstrations on the phantome. 

In my opinion, it would be right to admit, in a systematic arrange- 
ment, only two original positions of face-presentations: viz., one with 
the chin to the left, and one with it to the right of the pelvis; it being 
always understood, that the position is not necessarily exactly transverse, 
but that the chin may be variously addressed, sometimes, and indeed 
most generally being so far back as to be near the sacro-iliac symphysis, 



332 FACE PRESENTATIONS. 

and sometimes more anteriorly, or near the body of the pubis. By ad- 
mitting these two positions only, the Student's mind is relieved from the 
burden of unnecessary artificial distinctions ; and should he in practice 
rest upon them, it will be easier for him to comprehend the practical 
doctrines relative to the case. Thus, in all face cases, the great doc- 
trine is to bring the chin to the pubic arch, because the chin, being 
the mental extremity of the five inch mento-occipital diameter, may 
escape by gliding an inch downwards, behind the symphysis pubis; 
whereas, if it be directed backwards to the sacrum, it must slide five 
inches down the sacrum and coccyx, and from three to three and a 
half inches over the extended perineum, before it can be born; but, 
five inches and three inches make eight inches. The child's neck is 
not eight inches long. Therefore, before the chin can slide dow T n the 
sacrum, and off the anterior edge of the extended perineum, a good 
part of the child's thorax must be pressed or jammed into the exca- 
vation along with the head, the vertical diameter of whic^ is more 
than three and a half inches. See Figure 78, on p. 338. If we 
should adopt four positions, we must have a doctrine for each ; but 
with the two only, there is a necessity for only one doctrine — namely, 
to bring the chin to the arch of the pubis, if practicable; if not, let 
the forehead come, and do our best with it. 

Face presentations are accidents; and, perhaps, they are so unlikely 
to happen, in consequence of the normal lawof fcetal flexion, that they 
ought to be regarded as examples of preternatural labor. Yet, when 
we come to reflect, that the female can expel the child with but little 
more difficulty, in this case, than in vertex positions, it seems alto- 
gether proper to regard them as natural cases. But I have said 
that they are accidents, and I believe that they are chiefly caused by 
deviations of the axis of the womb. I beg leave to repeat, that if a 
female have a very great right lateral obliquity of the womb, and the 
vertex present towards the left side of the pelvis, it may be impelled 
against the brim in such a manner as to glance above it, and allow the 
forehead to fall into the opening, which state could not exist long with- 
out being followed either by the descent of the face, or the inducing 
of a shoulder presentation. It should not be forgotten that, from the 
chin to the vertex is a distance of five inches, which none of the dia- 
meters of the straits will take in, in the living subject: therefore, if 
the vertex should rise above the brim, and let the forehead fall into 
the opening, the chin w T ould gradually come down. Let not the Stu- 
dent then expect to find the face looking full down into the excava- 
tion, at the beginning of these cases; but rather, let him expect to find 



FACE PRESENTATIONS. 333 

it coming more and more completely down as the labor draws to its 
close ; hence, all face cases are at first cases of forehead presenta- 
tion, and whenever the chin departs from the breast in a labor, let 
him take heed lest it lead to a face presentation. 

I propose to the American Student to adopt Dewees' recommenda- 
tion, to have only two face presentations, and to let the first be that in 
which the forehead is to the left and the chin to the right side of the 
pelvis — while the second position is that in w T hich the forehead is to 
the right and the chin to the left side of the pelvis. Let this be the 
decision, and let the Student, when he finds the chin disposed to 
address itself to a point in rear of the transverse diameter, still con- 
sider it as a first position, or a second position, as the case may be. 

Suppose a case of face presentation to be caused by a right lateral 
obliquity of the womb, the point of the head being repelled above the 
edge of the strait: the womb, in its oblique state, leans to the right 
and forwards, and not directly towards the right ; whence, if the 
accident occur in the manner supposed, the chin could not fail to be 
placed to the right, and a little forwards ; the same thing is true of 
cases caused by left lateral obliquity — mutatis mutandis — as before 
stated. This furnishes a striking manifestation of the wisdom which, 
in giving form to the pelvis, even provided us herein a remedy for the 
accidents that might occur to thwart or prevent the parturient act. 
Should the chin be towards the posterior part of the pelvis, and not 
susceptible of being directed towards the front of the pubis, the most 
serious mischiefs might be expected to occur ; whereas, when the chin 
advances tow T ard the pubis, little embarrassment is, in general, to be 
apprehended. 

If we could know, antecedently to the descent of the presenting 
parts, what they are, it might be supposed that we could easily restore 
them when wrongly placed, to their proper situation ; but, while the 
presenting part of the child is above the brim, it is very rare to have 
such a good degree of dilatation as to admit of the hand being intro- 
duced, in order to effect the needful changes. The womb opens as 
the part comes down, and only as it does come down. Hence, when a 
face case is ascertained to exist, it is mostly (I say not universally) too 
late to return it into the abdomen or superior basin ; and as to attempt- 
ing to bring down the vertex, after the head has once sunk well into 
the excavation, I regard it as a rash, if not an impossible operation; 
rash, since it could not be done without very great violence ; and 
generally, impossible, since we cannot turn, or see-saw a diameter of 
full five inches, in a pelvis furnishing less than that space. Where it 



334 FACE PRESENTATIONS. 

is possible to push the whole mass back, and bring down the vertex, 
let it be done, if deemed really necessary; but the opportunity to do 
this good action will rarely occur in practice. 

Dead, and half putrid children, in whose tissues there is scarcely 
any resiliency or resisting power left, are not so unapt to come face 
foremost as living children, in whom departure of the chin from the 
breast occasions such a great extension of the head as to be painful, 
whence the child opposes the wrong tendency, by acting with all its 
strength, to get the chin down, or the head flexed again. 

Let me repeat that it is not to be expected, that, at the very beginning 
of a labor, the face of the child shall be found looking directly down- 
wards. When the examination is made early in a labor, the os uteri 
being dilated very little, the accoucheur ordinarily rests content with 
ascertaining that the head presents, and does not endeavor to complete 
the diagnosis as to position. Hence there is almost always a mistake in 
the diagnosis and prognosis, for it is the forehead that is first felt: and 
the face itself does not appear in the excavation for some time after the 
commencement of the parturient throes. The head turns over only 
by degrees, and allows first one eye to be felt and then the other, the 
nose, the mouth, and the chin. In order to exemplify these processes, 
I shall cite some cases from my record-book. 

On the 5th day of February, 1830, 1 was called to attend Mrs. , 

in labor with her second child. When I reached her house, it was 
half past six o'clock in the morning. She told me that she had had 
pain for a day or two, but was seized with regular labor-pains at four 
o'clock this morning. Upon making examination per vaginam, I 
found the os uteri from one inch and a half to two inches in diame- 
ter, with the edges thin and ductile, and the membranes protrud- 
ing through them very tensely during the pains. I could, at first, 
just feel the even smooth surface of the fetal cranium, which seemed 
to be resting or lodged upon the top of the symphysis pubis, and not 
in the least degree engaged, or entered into the superior strait; this 
was all that I learned from this first examination, and was all that I 
wished to learn. 

As the pains were regular and good, I expected soon to find the 
head engaged within the passage; but I observed that the uterus was 
very large, as if distended with an undue amount or excess of liquor 
amnii. 

At nine o'clock A. M., the pains, although regular and of increasing 
severity, had not caused the head to engage in the slightest degree: 
it remained exactly as at the first Touching. These circumstances 



FACE PRESENTATIONS. 335 

led me to suspect that the womb was unprovided with a proper degree 
of energy, on account of its being distended beyond its just dimen- 
sions. I, on this hypothesis, deemed it advisable to rupture the ovum, 
in the expectation that, as soon as the womb should condense itself a 
little by the flowing off of the waters, it would acquire such vigor as 
to compel the head to engage in the strait, and thence pass speedily 
into the excavation, as I had repeatedly observed to be the case in 
other persons. 

Upon rupturing the ovum, there came off a very great quantity of 
water; I should think nearly two quarts in all; but the head did not 
advance until three or four pains had acted upon it ; after which it 
came slowly down, and I felt a suture; but as yet no fontanel was 
distinguishable. The examination induced me to suppose it was a 
vertex presentation of the first position, in which opinion I was most 
egregiously deceived, in consequence of the very careless manner in 
which I made the investigation. At eleven o'clock I made a more 
careful inquiry, and was distressed to find that the left side of the os 
frontis was in the middle of the excavation, and that, by passing the 
finger very strongly up towards the left sacro-iliac junction, I could 
feel the left orbit and the nose, beyond which it was impossible for 
me to reach, in the then state of the organs of generation. 

It seemed, on account of the advanced state of the labor, too late 
to turn, even if that could have been considered the best recourse ; 
and I was the more averse to such a proceeding, considering that 
I had before delivered her of a large child, and also that the waters 
were now drained off, and the uterine contractions powerful. 

As she had by this time become heated, and very much disquieted 
with her pains, from which the suffering was severe, I gave her thirty 
drops of laudanum, and soon afterwards took twelve ounces of blood 
from the arm. She also got an enema of flaxseed tea and olive oil. 

The head was now fairly engaged, and the face was becoming 
more and more the presenting part, notwithstanding my repeated 
endeavors to push it up, by forcibly pressing against the ossa mala- 
rum during each pain ; and I became thoroughly convinced that it 
was impossible to force up the face and bring down the vertex by the 
employment of any legitimate force, or by mere dexterity. 

The pains had become so dreadfully severe, and the poor woman 
suffered such agonies, that I really entertained serious apprehensions 
that the womb might rupture itself or the vagina, in its vain efforts to 
carry on the parturient processes, lashed as it was into a rage of ex- 
citement by the obstacles to delivery. 



336 FACE PRESEXTATI G 1 K5 . 

A: my request Dr. James, at that time Professor of Midwifery in the 
University of Pennsylvania, was invited to see the patient, and arrived 
at two o'clock in the afternoon; and after having examined the case, 
left me, with encouragement to hope that the vertex might come down 
after some further efforts of the womb. Dr. J. was to return to me at 
half past four o'clock. 

In the mean time I provided myself with the long right-hand blade 
of Davis's oblique forceps; and when the professor returned, at four 
o'clock, it was found to be vain any longer to expect the descent of 
the vertex. I therefore introduced the blade above mentioned behind 
the right ramus of the pubis, got it upon the left parietal bone, and, 
using it as a vectis, drew down with it during the pains. The head 
advanced very much by this aid, and began to press upon the peri- 
neum; but there it stopped, and seemed no longer affected by the 

I next attempted, with my French forceps, to introduce the male 
blade behind the left obturator foramen. I was foiled, but Dr. James 
succeeded in adjusting it. Every attempt to adjust the female blade, 
whether made by Dr. James or by me, proved fruitless. They could 
not be made to lock; nevertheless, I attempted to deliver with them 
by securing the joint with one hand, and by this means the head 
again advanced, but soon stopped. The forceps were now aban- 
doned, after vainly attempting to make them lock. I next resorted to 
the oblique vectis again, and with it caused the head to advance so 
much, as to put the perineum in a state of tension. The face turned 
to the pubic arch ; the chin emerged from the genital fissure ; and as 
the successive portions of the face came forth, the chin rose up to the 
mons veneris, and allowed the fourchette to slip backwards off the 
vertex, which immediately retired towards the coccyx. 

The child was born, but the cord, which was tight around its 
neck, did not pulsate; the infant, however, began at length to gasp, 
and, after having been well dashed with brandy, cried lustily. It 

s born at half past six o'clock P. M., so that the labor was found 
to have continued about fourteen or fifteen hours. 

A: the time I last put on the vectis the child's face was in the left 
sacro-iliac corner of the pelvis. Both Dr. James and I expected that 
the rotation would inevitably carry the chin to the sacrum, to be 
consequently delivered at the perineum. I have every reason, there- 
fore, to suppose that the vectis was the chief means of giving the head 
m favorable a rotation, a result attributable to the admirable curve of 
Dr. I :lique blade. 



FACE PRESENTATIONS. 337 

The perineum was not hurt; the placenta came off in twenty- 
minutes ; and the mother found herself very comfortable, considering 
her great fatigue. 

The face was one enormous suggillation, carried to the extent of 
producing numerous blebs or vesications on the eyelids and cheeks. 
The mouth was excessively swelled, and the left eye completely 
closed. The face was, on account of this state, directed to be fre- 
quently bathed with cream. This infant was carefully weighed on 
the evening of its birth, and was found to weigh nine pounds and 
three-quarters. On the sixteenth day after delivery, the woman was 
down stairs to dinner, and had no subsequent indisposition. 

In giving the details of this case, I am liable, as I well know, to 
the charge of having, in an important matter, anticipated my subject. 
But although I have not yet come to the formal consideration of in- 
strumental cases, I feel pretty well assured no evil will happen to 
any Student for having, by reading the foregoing relation, in some 
degree anticipated the regular and formal consideration of obstetric 
operations. 

The cut, Fig. 78, which represents the foetal head, in a face labor, 
thrown back to that degree as to press the occipital bone against the 
interscapular space, suffices to show how well founded were my fears 
lest the forehead, instead of the chin, should rotate to the front, to pre- 
vent which is the chief doctrine of this obstetric topic; and I would 
again urge the Student to take the first opportunity that may present 
itself, of testing the doctrine, by trying to deliver on the machine, or 
phantome, with the chin backwards, in a face presentation. By so 
doing, he will at once have a demonstration of the point of practice 
to be adopted, and never afterwards be in the least danger of making 
a mistake, or committing a blunder in this matter. 

Seeing the great and merited reputation of the late Professor De- 
wees, of Philadelphia, and the general recourse to, and reliance on 
his obstetric precepts, I feel constrained to warn the Student of one 
error in his System of Midwifery, 2d edition, 1828. He is speaking 
at p. 328, of the instrumental delivery of a face-labor. 

" Should the forceps be determined on, we must apply them over 
the ears; that is, one blade behind the pubis, and the cither before the 
sacrum ; they must be so applied that the concave edges must look 
towards the hind head, which must be brought under the arch of the 
pubis, and not the chin, as directed by Smellie." 

This operation would inevitably, if successful, bring the top of the 
forehead and the crown of the head under the arch, and the chin to the 
22 



338 



FACE PRESENTATIONS. 



sacrum and the coccyx as in Fig. 78. To deliver it, would imply that 
the child's throat should stretch to a length beyond eight inches ; or 
that the thorax and head should both be in the excavation together. I 
should not have noticed this lapsus of my celebrated townsman, but as 
evidence of my respect for his great reputation, and because I know 
that it was lapsus pennse, and not a precept that he would follow in 
practice. When such authorities happen to fall into even a small 
error, it is proper to point out the error, lest a great name should 
mislead the early beginner, or Student. 

I should think no long disquisition would be required to convince 

the Student who will carefully ex- 
Fi s- 78 - amine the Fig. 78, that in a face 

presentation with the forehead to 
the pubis, and the chin to the 
sacrum, it must happen that a 
considerable part of the child's 
thorax shall be jammed, together 
with the cranium, into the pelvis. 
The same cut shows that if the 
occipito-mental diameter be re- 
versed, so that the mental extre- 
mity of it, instead of the occipital 
extremity, enters the pelvis first, 
it must leave it first, for it cannot 
be reversed within the excavation. 
Further, let the Student examine the drawing, to see how the chin 
must in these unfortunate presentations slide down the posterior surface 
of the pelvis, from the promontorium to the point of the coccyx, and 
so over the perineum, until it escapes from the vulva, over the four- 
chette. In examining Fig. 75, he will readily perceive how easy it 
is for the mental extremity of the oblique diameter to begin to escape, 
since it has only a slide of one inch along the symphysis pubis to 
make before it emerges; whereas, in the reverse position it slides five, 
six, or even seven inches over bone and resisting tissue, before it can 
begin to be born. 

A case of a"*different kind occurred to me on Wednesday, the 17th 
of February, 1830. Mrs. M. was in labor with her seventh child, 
having been taken at four o'clock A. M. with the pains, which con- 
tinued to increase up to the time when I arrived, which was about half 
past six o'clock. The pains were strong; the w T aters gone ofT; and 
the head pretty low T down in the pelvis. At my first examination, I mis- 




FACE PRESENTATIONS. 339 

took the presentation, thinking that it was a vertex case ; but as the 
pains seemed to have no good effect, I examined again, and could feel 
the root of the nose directly behind the symphysis pubis, and the super- 
ciliary edges of the orbits upon each side of the symphysis of the bone. 

Upon this discovery, I endeavored to turn the forehead towards the 
left, by raising the os frontis, and pushing it in the proper direction; 
but as soon as each pain came on, it forced the presenting part back 
again into its former position. I next endeavored, by simply pushing 
up the forehead during the absence of a pain, and sustaining it while 
the pain was active, to cause the vertex to descend along the curve 
of the sacrum, and the perineum : but I could not succeed here any 
better than in my attempts at rotation; the pains drove it back, mau- 
gre all my wishes to the contrary. As the chin was so far departed 
from the breast, I had good reason to fear that the head must turn 
quite over in extension, and thus give me a face case to manage, for 
as I could feel the superciliary ridges on each side of the symphysis 
pubis, there was some likelihood of a complete overset of the head, 
provided the cranium was not too large. 

The patient, who had met with no such difficulties in her former 
labors, and to whom I was a stranger, now became greatly alarmed 
and distressed ; so much so, indeed, that I judged it most prudent to 
explain to her the true situation of affairs, and encouraged her to look 
for relief after a reasonable time. I told her that she could be deli- 
vered by her own unassisted efforts, but that it would take a good 
deal of time and much pain; but that I could speedily deliver her 
with the help of an instrument, which would add neither to the hazard 
or pain of her condition. She clapped her hands, trembled violently, 
and uttered exclamations indicative of the greatest dismay, and even 
terror, but at last agreed to be guided by my opinion. 

I introduced the right-hand long blade of Davis's oblique forceps, 
with which I caused the head to make a considerable advance; but 
it again stopped, and I applied the long forceps: with the aid derived 
from this instrument I drew the head downwards so as greatly to 
extend the perineum; upon observing which I deemed it prudent to 
remove the forceps, lest I might rupture the perineum, which was 
about to undergo, unavoidably, a very great distension, and which I 
was not inclined to augment unnecessarily. After removing the for- 
ceps I reapplied the vectis, as before, and it very greatly assisted me 
to bring the head onwards as far as was requisite. As soon as I 
withdrew the vectis a pain came on, by which the head was expelled, 
the vertex passing out over the fourchette, upon which it immediately 



340 FACE PRESENTATIONS. 

completed its act of extension, and allowed the crown, forehead, nose 
and chin successively to escape under the pubic arch. The child 
was born alive, and the after-birth followed in ten minutes. Upon 
the infant's forehead was an enormous black suggillation, which 
disappeared in the course of a few days, and was followed by no 
inconvenience. 

Of the above case it is proper to remark that the mother was very 
w 7 ell formed, and the pelvis large ; the child of medium size ; and 
although it did not become actually a face presentation, but was 
rather a case of presentation of the forehead, it still serves to illus- 
trate my observations on the difficulty of converting face presentations 
into those of the vertex. I think that, but for the aid of the instru- 
ments, it must have at last brought the face from behind the top of 
the symphysis pubis to look fully down into the excavation ; for the 
difficulty of bringing down the vertex, although not insuperable, was 
exceedingly great. In the course of my practice I have met with a 
considerable number of cases like the one whose relation I have just 
given, but it seems unnecessary to cite them here, as I presume this 
one may suffice to explain the nature of the mechanism of such a 
labor. 

I find, in my case-book, another example of face presentation, 
which I shall not deny myself the privilege of laying before my reader 
in this place, because it offers good encouragement to those who may 
happen to meet with such untoward sorts of labor in the commence- 
ment of their practice. 

October 11th, 1830. Mrs. C. W., aged twenty-six, was in labor 
with her first child. I was called at twelve o'clock at night. She 
had been poorly throughout the day, but kept about until bed-time. 
At ten, P. M., had a violent pain and large discharge of waters. She 
lay on her left side. Upon Touching, I could not reach the os uteri, 
nor feel any part of the child. Upon causing her to turn on the back 
I was enabled, by pushing the finger very far upwards and back- 
wards, to hook the anterior lip of the os uteri, and draw it, by means 
of the finger, downwards and forwards, into the centre of the plane of 
the upper strait: I could then touch the child's cranium, but I could 
not touch a sufficient portion of it to learn what part of the cranium 
it was. Not long afterwards I felt, in the left anterior part of the 
upper strait, a ridge or edge, which I soon made out to be the super- 
ciliary edge of the orbit of the left eye, the globe of which soon came 
within my reach. I could not touch the anterior fontanel. 

Here, then, was a case which, like that just now related, was to 



FACE PRESENTATIONS. 341 

become a face presentation at last, if I should prove unable to pre- 
vent it by failing to restore to the head its lost flexion. I vainly tried 
to do this by pushing up the forehead, and holding it up during a 
pain. It always came back to its place, in spite of whatever efforts 
I could make. I next introduced the whole hand, except the thumb, 
took hold of the vertex by a fair purchase, but could not turn it down- 
wards ; and at length, becoming convinced of the impossibility of 
succeeding, resolved to abandon such irritating interference. 

As the head sank lower and lower, there was an obvious tendency of 
the chin towards the left sacro-iliac junction. I opposed this move- 
ment of the head by pressing the finger on the right side of the nose, 
which kept it from turning to the left, and at last brought it to the 
obturator foramen. The face came more and more down into the 
excavation, and began to swell very much. The lips became exces- 
sively tumid, and the whole face at last felt like a tense bladder. By 
the force of the pains, alone, the chin w T as afterwards slowly brought 
to the os externum, and applied itself to the top of the pubic arch, 
under which little by little it emerged, and then rose up towards the 
mons, permitting the front of the throat to take its place under the arch, 
and thus allowing the vertex to escape last from before the fourchette. 
See Fig. 77, p. 330. 

The placenta came off in six minutes. The infant was very weak, 
and its face greatly swollen, and black with the suggillation. It soon 
cried loudly, and I found that on the 14th, that is three days after its 
birth, it was in fine health, and wuthout any swelling of the face. 
The mother had a very favorable getting up. The net weight of the 
infant was nine and a half pounds. The mother was a large and 
very powerful woman. 

Madame Boivin informs us in her Memoires sur VArtdes Accouche- 
mens, page 276, that out of seventy-four cases of face presentations, 
fifty-eight children w T ere born naturally. Of these, forty-one were 
delivered without any assistance, and seventeen, by restoring the 
vertex to the centre of the excavation ; a success almost incredible. 
Fourteen cases required the turning and delivery by the feet, while 
only two were extracted by the forceps, and in one of the latter cases 
the mother had convulsions. 

"Thus," says the learned lady, "although presenting by the face, 
the child may be born alive and naturally, provided the head be not 
too large, if the parts of the mcther are well formed, the pains strong 
and good, the woman resolute and healthy, and no accident occur 
during the course of the labor." 



342 FACE PRESENTATIONS. 

Madame Lachapelle, whose vast experience, gained while at the 
head of the Maternite Hospital at Paris, is yalid claim to speak as 
from authority, and whose thorough knowledge of the theory of mid- 
wifery must confirm those claims as rights, gives us only two sorts of 
face presentations : one in which the forehead is to the left and the 
chin to the right of the pelvis, and the other in which the forehead is 
to the right and the chin to the left. She says she never met with 
Baudelocque's first and second positions ; and Dr. Dewees, who 
asserts that his list comprises near nine thousand labors, also informs 
us that he never met with them. It will be remembered by the reader 
that the second case which I related in this chapter, that of Mrs. M., 
was one in which I felt the root of the nose behind and above the 
symphysis, and the two orbits on each side of it; and he will admit 
that although the vertex was at last restored so as to escape first, yet 
this was a real example of a face case of the rarest occurrence. 
Smellie gives us at least four examples of the face presenting in 
Baudelocque's first or second position; and assuredly no English or 
American Student of midwifery will be disposed to call in question 
the accuracy or candor of that admirable author, notwithstanding that 
Madame Lachapelle tells us she finds no very evident examples of 
such face positions in any good collection of cases. 

For my own part, I do not perceive the great importance of dwell- 
ing with much emphasis upon all the possible positions of the face. 
It cannot be doubted that they are each possible, inasmuch as, where 
the child's head is not disproportionately large, the mass of the head is 
observed to rotate upon the cervical axis, as I before remarked, some- 
times threatening to carry the chin towards the sacrum, and some- 
times flattering the accoucheur with the prospect of its speedy arrival 
at the pubis. The more important and useful knowledge is that 
which teaches us the nature of the accident, and the appropriate 
indications of treatment. But we have already seen that the acci- 
dent consists in an excessive departure of the chin from the breast, or 
failure of flexion; that is the first principle: and the chief indication 
founded upon it is, to restore the flexion by pushing up the forehead 
and bringing down the vertex; and where that cannot be done, the 
next indication is, to rotate the chin to the front so that flexion may 
take place as soon as possible after the chin has emerged. 

I am not capable at present of stating the number of face cases I have 
had occasion to treat. The number has been considerable. The result, 
as to my opinion, is, that they are rarely formidable when the great 
precept of bringing the chin to the pubis can be obeyed and fulfilled. 



FACE PRESENTATIONS. 343 

Certainly, I have not been in a majority of my cases called upon to 
use any extraordinary measures of relief. 

I have a word of counsel for the Student as to the care of his own 
reputation in the conduct of such cases. There can rarely be met 
with a more disagreeable spectacle than that of a new-born child's 
face, born after a bad face labor. It is frightfully suggillated, and 
often covered with blebs filled with yellow or bloody serum, the lips 
are completely ectropied, the eyes closed by infiltration of the palpe- 
bral, and the nose enormously swollen. By-standers cannot compre- 
hend why these appearances should exist in a neonatus that has been 
tenderly treated — and are therefore too apt to assign as the probable 
cause the rudeness and brutality of the medical man. As soon as 
the young beginner has surely made his diagnosis, let him announce 
the probability of a swollen and blistered face, notwithstanding the 
gentleness of the treatment which he is about to administer. In this 
way he may save and augment not only his own credit, but that of his 
art, a pleasing duty for every true scholar. 

As I shall have occasion to revert to the consideration of face posi- 
tions when I come to treat of the various uses of the forceps, I shall 
close the present chapter, in order to take up the consideration of those 
labors in which the child presents the breech, knees, or feet, when 
descending. 



344 PELVIC PRESENTATIONS. 



CHAPTER XII. 

ON PRESENTATIONS OF THE PELVIC EXTREMITY OF THE FCET17S. 

As the length of the gravid uterus, at full term, does not exceed 
twelve inches, and as a well grown foetus is nineteen or twenty inches 
in length, it is evident, as I have already said, that it must, while in 
utero, be folded up in a very compact form, and that it will be an 
oval body, one of the extremities of which ought to be directed to- 
wards the orifice of the womb, and the other to the fundus. The 
most natural position of the foetus is certainly that in which the head 
points downwards ; so that the vertex, or some other part of the head, 
may, in labor, advance first. But it happens that about one in every 
forty-five or fifty cases presents the other extreme of the ovoid to the 
os uteri ; and, in doing so, it is a matter of mere chance whether the 
breech, or the knees, or the feet, prove to be the presenting part. In 
strictness, the breech ought to descend first in these labors, but if the 
feet happen to be near when the membranes give way, they are quite 
likely to fall into the opening, and pass, soon afterwards, out at the 
vulva ; so that, supposing the breech presentation to be, after those 
of the vertex, the most natural, we may properly include, in the 
account of the presentations of the pelvic extremity, those of the knees 
and feet, and regard them as mere accidents of the pelvic presenta- 
tions, and all to be included under the head of natural labors. 

Agreeably to the doctrine expressed in a former page of this work — 
a doctrine that announces two essential presentations of the foetus, 
one a cephalic, and the other a pelvic presentation — each of them is 
liable to the accidents appurtenant to their form, firmness, &c. 

It is not an easy matter to determine why the breech presentation 
occurs about once in forty-five or fifty labors, and it is far less easy 
to say what is the reason that certain women are prone to this sort of 
labor to such a degree as to bring all their children so. I knew a 
woman whose children, three in number, were all born with the breech 
presentation, and it is by no means very rare to meet with persons 



PELVIC PRESENTATIONS. 345 

who have been similarly situated in more than one of their labors. Dr. 
Collins, of Dublin, in his Practical Midwifery informs us, that one 
woman who was delivered at the Dublin Lying-in Hospital had pre- 
ternatural presentations in every one of her labors, and she had given 
"birth to nine children. While that gentleman was master of the 
Dublin Hospital, sixteen thousand four hundred and fourteen women 
were delivered, of whom three hundred and sixty-nine had presenta- 
tions of the breech, feet or knees ; making rather more than one such 
labor in every forty-five cases. Out of 54,723 labors stated by Baer, 
Bland, Merriman, Boivin, Lachapelle and Nagele, there were 1694 
cases of breeeh, feet or knee presentations, which gives us one pelvic 
presentation in thirty-two and one-fifth cases nearly. It is commonly 
assumed that about one in forty-eight, or more generally two in 100 
cases will prove to be pelvic presentations. 

Causes of Pelvic Presentations. — The causes which produce 
these presentations must be purely accidental. The natural present- 
ation is that of the head, which is turned towards the os uteri from 
the earliest period of pregnancy. The attachment of the navel string 
is nearer to the pelvis than to the head of the child, the head there- 
fore hangs downwards; but when the cord, by the growth of the 
ovum, has become of a very considerable length, the child ceases to 
be dependent from it, for the cord is not unfrequently from twenty to 
thirty inches long. It seems very probable that while the fcetus is yet 
small, it may change its position in the uterus; but if it happen to 
turn as late as the fifth month, it will be apt to retain the attitude it 
may then acquire till the end of the pregnancy, as its length does not 
admit of its changing again very readily after that period. It is not 
to be doubted, however, that the attitude may be reversed, by certain 
extraordinary or violent movements of the mother, at a later period, 
so that the head, which was originally at the os uteri, may be brought 
to the fundus, and vice versa. 

Some persons will not agree with me in regarding the pelvic as a 
natural labor, but, notwithstanding that the breech presentation is 
met with only once in forty-five or fifty labors, I am not inclined to 
regard it as a preternatural case, for I cannot discover any reasons 
for classifying it with that sort of births, in the mere fact that the head 
does not present. The breech composes one end of the foetal ovoid; 
and a breech labor requires, for its complete success, no greater dila- 
tation than that demanded for the passage of the head : it may be 
effected without any aid, and is, perhaps, not really fraught with 



346 PELVIC PRESENTATIONS. 

greater danger for the mother than the other, the common vertex pre- 
sentation. It is, however, far more dangerous for the child than the 
vertex case; and as the object of parturition is the safe birth of the 
infant, it might be absolutely proper to include, in the class of pre- 
ternatural labors, all those in which the child is exposed to unusual 
hazard. Still, many breech presentations terminate favorably with 
great celerity and without any artificial aid, whence I look upon them 
as not really preternatural. 

In former times these presentations of the pelvic extremity of the 
foetus were regarded as much more serious events than they are at the 
present day. That sprightly and most delightful old book — the first 
Midwifery book ever printed in England — I mean the Byrth of Man- 
kind, by Thomas Rainald, Lond., 1565, ab Fol. liiii., has the fol- 
lowing : 

" Agayne, when it proceedeth not in due tyme, or after due fashion, 
as when it commeth forth with both feete, or both knees together, or 
els with one foote onlye, or with both feete downwards, and both 
handes upwardes, other els (the whiche is most perillous) sidelong, 
arselong, or backlong, other els (having two at a byrth) both proceade 
w r ith theyr feete fyrst, or one with his feete, and the other with his 
head, by those and dyvers other wayes the woman systayneth great 
dolour, payne and anguishe." 

Thomas Rainald would be very much surprised and comforted 
could he see what facilities modern science has provided for the obvi- 
ation of all these terrible occasions. 

The danger to the child, here, depends on its liability to asphyxia, 
from several causes: first, the compression of the cord, which is 
pressed betwixt the child and the parts from which it is escaping; 
second, the detachment of the placenta before the head is born, by 
which the uterine life of the child is destroyed before its birth ; thirdly, 
the compression of the placenta itself betwixt the uterine parietes and 
the head of the infant ; or fourthly, the constriction of the placental 
superficies of the womb during the time that the child's head, still 
remaining in the vagina and lingering there, ceases to distend the 
uterus, which closely contracts on the after-birth, and even if still 
retaining its connection with it, yet suspends all the utero-placental 
operations on which the foetus depends for existence, antecedently to 
the establishment of respiration. 

The last named cause is, I presume, the one chiefly to be feared ; 
and I have long deemed the pressure upon the umbilical cord, in 
breech cases, a matter of small moment as to the child's security, in 



PELVIC PRESENTATIONS. 347 

comparison with the asphyxiating influence of the compression, de- 
tachment, or constriction of the placenta by the reduction of the su- 
perficial contents of the placental seat. It is probable that that seat, 
which is eight inches in diameter before the commencement of the 
labor, is diminished to a diameter of four or even perhaps three inches 
by the time the head is driven out of the womb. Under such a re- 
duction no valid placento-uterine inter-communion can be supposed 
possible. 

The breech may descend into the excavation, and it may even pass 
through the vulva, without the least danger of compressing the cord; 
but when the body of the child has sunk so low as to bring its navel 
down into the bony pelvis, there is danger that the arteries of the 
cord may be completely obstructed for a period long enough to give 
the child a fatal asphyxia. Such an event is far more likely to occur 
where the feet present than where the breech advances; because, in 
the latter case, the thighs, and generally the legs, are extended along 
the front of the body in such a manner as to protect the cord from 
pressure, its vessels being fully guarded by its position betwixt the 
thighs, during all the time the body is- escaping, thus enabling the 
infant better to bear the temporary pressure on the cord for the short 
time it is compressed only by the head, while that part stops in the 
excavation: longer pressure by the head would easily extinguish the 
remains of a life that was already about to expire from preceding 
obstruction of the circulation. In general, the danger for the child is 
not great until the head has sunk down into the excavation, because 
it commonly does not take a great deal of time for the whole of the 
body to pass through the canal of the pelvis; but the head, being 
subject to arrest while in the passage, may then fatally compress the 
cord betwixt itself and the bony sides of the pelvis. 

We know that the prolapsion of the cord in an ordinary labor, is 
very apt to occasion the death of the foetus ; and it is therefore easy 
to perceive that such compression of the cord, between the foetal head 
and the pelvis, is the real cause of the loss of the infant. From this 
we might naturally suppose, that the children that are lost in breech 
and footling cases are lost from the same cause, to w T it, a compression 
of the cord. But I believe, upon evidence, that the placenta is often 
detached as soon as the head or breech leaves the uterine cavity; and 
if so, then the child is rather lost from the suspension of the placento- 
fcetal circulation by the aforementioned detachment, than from the 
compression of the cord only. 



348 PELVIC PRESENTATIONS. 

Fatalities in Breech Cases. — I think it probable that more than 
one child in every five that presents by the breech, or feet, or knees, 
perishes in the birth. In large lying-in hospitals, perhaps, the pro- 
portion of fatal cases is rather less unfavorable, in consequence of the 
prompt attention always paid in such establishments to the parturient 
female, and to the greater skill and dexterity acquired by abundant 
opportunities of practice. Of Dr. Collins's cases, 369 in number, of 
breech, feet, and knee presentations, 234 were born alive, and 135 
were born dead- — some of which were putrid, premature, &c. 

In Dr. Cazeaux's Traite Theorique et Pratique de VArt des Ac- 
couchemens, a work published in Paris in 1840, and which is said to 
enjoy the very highest favor in France, there are the following re- 
marks upon the subject of the danger to the foetus in pelvic presenta- 
tions. I translate it as containing a late novelty upon the sub- 
ject. " Delivery by the pelvic extremity is very dangerous for the 
child. The statistical results furnished by Madame Lachapelle prove 
that out of eight hundred and four presentations of the pelvic ex- 
tremity of the foetus, one hundred and two children were born feeble, 
and one hundred and fifteen were born dead. The proportion of dead 
children to the whole number is one-seventh; whereas, in 20,698 
vertex positions there were only 668 dead born: which is one in 
thirty, or about one-thirtieth. As to the prognostics of the several 
sorts of pelvic presentations, it has been remarked, that when the 
breech comes down first, the number of dead born is about one to 
eight and a half, which is an eighth and a sixteenth. In footling 
cases, one out of six and a half die, a sixth and more ; and lastly, for 
the knee cases, one out of four and a half." 

M. Cazeaux goes on to say, that the above is not a fair representa- 
tion of the dangers to the child, in these cases; for these results do 
not exclude those cases of dead born that are not properly assignable 
to the pelvic presentations as causes of the death ; the statements 
ought to exclude putrid foetuses and deformed children ; and he states, 
as the opinion of M. P. Dubois, that, " setting aside all the cases in 
which the children appear to have been lost from causes not connected 
with the presentation, M. P. Dubois has arrived at this result, that in 
labors with footling presentations, there dies one child out of eleven, 
whilst in presentations of the head there dies one out of every fifty. 
It is plain that the difference is frightful." Cazeaux, p. 359. 

Diagnosis. — It is a question whether the nature of the presenta- 
tion can be discovered by reference only to the movements of the 



PELVIC PRESENTATIONS. 349 

foetus in the latter stages of gestation. Some persons have foretold 
that the child was improperly placed, judging it so to be by feeling 
a greater degree of motion in the pelvic region, than in the upper 
part of the uterus. It seems not difficult to believe that if the mo- 
tions of the child should be chiefly felt towards the cervix uteri, they 
ought to be accounted for by referring them to the presence of the 
feet in that quarter. However, I feel assured that those patients whom 
I have attended, and whose labors were accompanied with this pre- 
sentation, were in general utterly unsuspicious of it in pregnancy; 
and are, commonly, ignorant of it until the child is born. It is not 
rare, indeed, for women to fear that the child is to be born double, as 
it is called, when the vertex really does present ; and some patients 
are quite convinced the child is wrongly placed, until labor comes on 
to prove their fears ill founded. There may be some certainty, per- 
haps, of a diagnosis derived from the stethoscope applied to different 
parts of the uterine region; for, if the child's head be directed towards 
the fundus uteri, there will be, in consequence, a pulsation of its heart 
at a higher level than if the head occupy its more natural position — 
probably near the navel ; but there will always remain some liability 
to wrong impressions, if they be derived from auscultation alone. 
The surest way is that of the Touch, which is scarcely to be confided 
in except at the commencement of labor, or at a period when the pre- 
sentation can be touched with the tip of the finger. 

When the breech can be reached per vaginam, it ought to be recog- 
nized by its mass filling up the pelvis ; by its softness, and its fleshy 
feel, so different from that of the foetal head ; by the tubera ischii ; by 
the point of the coccyx, the anus, and the organs of generation, male 
or female ; by the spines of the sacrum, and by the sulcus found be- 
tween the nates and the thighs, which tend upward from the presenting 
part — I may add, also, by the meconium, which is often discharged 
at a pretty early stage of labor, and comes away with the waters on 
the hand of the accoucheur : but let not the young accoucheur be 
deceived by this symptom, since it is possible for portions of the meco- 
nium to come away even in the best vertex position. It is also to be 
observed, that the form of the bag of waters is commonly not so much 
like a segment of a sphere in the presentations of other parts than the 
head. In breech presentations, it is more like an intestine in shape, 
sometimes descending to the very orifice of the vagina, and yet not 
very considerably dilating that passage. 

Notwithstanding we ought to be able clearly to distinguish betwixt 
the breech and the head presentations by the first touch, it is, I think, 



350 PELVIC PRESENTATIONS. 

not very uncommon for us to make a great mistake, if I may judge 
from the instances of mistakes that have come under my knowledge ; 
but I am sure that such errors are the results of mere carelessness, 
and they could therefore always be avoided. Let it not be here un- 
derstood that when the true nature of the presentation is known, it 
ought to be communicated to the patient ; on the contrary, it should 
be carefully concealed from her, as not calculated to promote her easy 
deliverance, since she attaches to the circumstance the idea of greater 
suffering or danger, which, by depressing the powers of her mind, 
would be very apt to affect, in an injurious manner, the pains or the 
voluntary efforts that she ought to have in their greatest vigor. "While 
the nature of the case, then, is carefully concealed from the patient, 
it should be formally announced to her husband, or to some respon- 
sible person, and all the hazards of such a situation for the infant 
should be explained, in order that if any untoward event should cause 
the infant to be still-born, no unjust imputations might lie against the 
candor, the skill, or dexterity of the accoucheur. 

Not to Bring Down the Feet. — When the breech is found to be 
the presenting part, it is very natural to suppose that, could the feet 
be brought down, they would give us the command of the child, so 
that we could very greatly assist in its delivery ; and this is quite 
true: nevertheless, it is bad practice to bring the feet into the vagina, 
except for some very well understood and sufficient cause. When 
the child descends double, as it is called, the parts yield very slowly 
for its advance, and this tediousness is a necessary consequence of 
its bulk, and the yielding nature of its structure : unlike the head, 
which is hard and firm, this part, when urged downwards by the 
pains, gives way before them, and is compressed so much that each 
pain is half lost before the part becomes firm or condensed enough to 
make it act as a dilater. This slowness is greatly to be deprecated ; 
and all proper means to obviate it may be safely resorted to, such as 
a venesection, or the administration of a clyster or a dose of castor 
oil, &c. ; yet this very slowness, and the great size of the breech, 
serve as means for the child's security at the last moments of labor. 
By their means the os uteri, vagina and vulva are so completely 
opened, and so entirely deprived of the power of resisting, that, when 
the head comes to take the place of the body in the excavation, a 
very little force of the woman's straining serves to extricate the head, 
or at least the complete dilatation enables the accoucheur to employ 
his hand or his forceps to extract the head in time to save the child 



PELVIC PRESENTATIONS. 351 

from an asphyxia, which is almost sure to affect children that are not 
born very soon after the escape of the shoulders, during the time the 
head is in the vagina ; and the placenta would be so completely 
squeezed by, or even separated from, the womb, that the utero-pla- 
cental functions must cease to be performed. 

The impatience, which can scarcely be avoided by persons wit- 
nessing the throes of the mother or the struggles of the child, also 
exposes us to the danger of doing it a great harm by pulling strongly 
by the breech, shoulders, &c, in order to get both mother and infant 
the more speedily released; but if any one will take the time to reflect 
that the spinal marrow may be greatly injured by a violent extension 
of the neck, it will be evident to him that no very great amount of 
extracting force ought to be applied. It is best, therefore, as a gene- 
ral rule, to permit the breech to descend, and not in any manner to 
interfere with the feet until they are spontaneously born. Any ex- 
tracting force has an invariable tendency to slip the arms upwards, 
so as greatly to embarrass the last and most important act of the 
breech labor. When the child is wholly expelled by the uterine con- 
traction, it is pushed out of the womb in consequence of the approach 
of the fundus to the cervix of that organ. In that natural process, if 
the arms happen to be resting on the sides or abdomen of the child, 
they ought to descend pari passu with the parts on which they rest ; 
but if the child be pulled out, then, as the fundus uteri does not press 
with a proper power upon the head, the arms will naturally slip up 
over or along-side of its head, where they sometimes are so firmly 
fixed as to make it a very difficult matter to bring them down. 
Hence the soundest discretion teaches us to let the womb push forth 
the breech as we let it push forth the head, without laying hold of it 
to drag it downwards as soon as the least purchase can be had on the 
presenting part. 

The legs, in a breech presentation, may be turned upwards on the 
child's belly, or they may be flexed on the thighs, so as to bring the 
feet very near the nates. If the breech engages in the pelvis, or be- 
gins to pass the circle of the os uteri, the feet disappear, rising as 
the nates descend. There is no danger of injury to the hip or knee- 
joint, if the child be trusted to the natural powers employed for its 
birth or expulsion ; but whenever much force is employed by putting 
the fingers in the groin, we do incur the hazard of breaking or dislo- 
cating the thighs. 

The breech may have one of four positions : 1st. The child's back 
to the left acetabulum of the mother ; 2d. To the right acetabulum ; 



352 



PELVIC PRESENTATIONS. 




3d. To the pubis : 4th. To the promontory. These several positions 
are easilv discriminated in practice by the Touch, which ought not to 
mislead any attentive or considerate practitioner, since by the Touch 
it is easy to learn where are the coccyx, the tubera ischii, the genitals, 
the sulcus betwixt the thighs, the sacrum, &c. &e. 

As the escape of the breech occasions a great distension, the peri- 
neum requires very steady support by pressing a sort napkin against 
it, for the purpose, first, of resisting the too rapid advance of the 
breech, and second, in order to give to its movement that curvilinear 
direction which ushers it into the world in a 
course coinciding with the line of Carus' 
curve. The Fig. (79) exhibits to the Student 
the appearance of bending which is acquired 
by the pelvic extremity of the trunk while 
passing outwards in a breech labor. It is 
manifest that the perineum may be here sub- 
jected to a great degree of distension. As 
soon as the body is so far born as to permit 
the navel string to be' reached, it is to be drawn 
downwards a little, so as to free it from the 
danger of being broken off, or the greater 
danger of a too early detachment of the placenta. It is easy to draw 
a considerable loop of it downwards by pulling at the yielding por- 
tion, as in Fig. SO. As soon as the 
feet are delivered and extended, they, 
as well as the body, should be wrap- 
ped in a napkin, in order that the skin 
may not suffer any injury, and also 
for the purpose of enabling the ac- 
coucheur to hold it more firmly, which 
he could not otherwise do on account 
of the viscous nature of the sub- 
stances that adhere to it soon after it 



First Position. — In the first posi- 
tion of the breech, the child's left hip 
should rotate to the left towards the 
pubis, so as to allow the sacrum to 
glide down along the left ischium, 



Fig. so. 




PELVIC PRESENTATIONS. 



353 



Fig. 81. 




and the right hip to fall into the hollow of the sacrum. Fig 81 shows 
the pelvic presentation in situ before rotation, while Fig. 79, above, 
exhibits the appearance after rota- 
tion has taken place. But after the 
hips are fully delivered, they re- 
cover the obliquity of their former 
situation, and the body continues to 
descend so, until the shoulders, en- 
tering into the pelvis in an oblique 
direction, come to rotate as did the 
hips, the left shoulder advancing 
to the pubis and the right one fall- 
ing back into the hollow of the 
sacrum. In Fig. 80 may be seen 
where the right shoulder has come 
to the pubis and the left to the sa- 
crum. When the shoulders do not 

come down well, a ringer should be passed up so far as to reach 
above the one that is nearest at hand, to depress it by drawing it 
along with the finger, which commonly suffices to cause the arm 
to escape. But if the arm does not descend readily, let the finger 
be slid along its upper surface to a spot as near as may be to the 
bend of the elbow, and then the elbow may be drawn downwards 
with considerable force, and without any danger of fracturing the os 
humerus. One arm having escaped, there will be little difficulty or 
delay in getting the other down, especially if care be taken to move 
the body in a line of direction opposite to that part where the arm is 
detained. 

As soon as the arms are delivered, an examination should be made 
in order to learn how the head is situated. If the face is found in the 
hollow of the sacrum, and the chin well down towards the fourchette, 
it is well. The child's body ought now to be raised upwards on the 
practitioner's arm, to a height sufficient to enable the longest axis of 
the head to become parallel with the axis of the vagina, and the 
patient pressingly exhorted to bear down and force the child out of 
the passage ; for at this time the head is not in the womb, but in the 
vagina, and for its expulsion there is required rather the effort of the 
abdominal muscles than that of the uterus, which doubtless does, in 
many instances, partially close its orifice above the vertex, in this 
stage of a footling or breech case. If the patient therefore does not 
make a very great effort of bearing down, or expulsion, the head 
23 



354 PELVIC PRESENTATIONS. 

must remain in the passage, during all which time the child is ex- 
posed to the risk of perishing by asphyxia. It is true that the pres- 
sure of the head upon the parts tends to produce a violent tenesmus, 
which compels the woman to strain very much; but it is also true 
that in some instances she will not make the smallest effort, unless 
urged or commanded in the most earnest manner by the physician. 

Some aid may be given at this critical moment by drawing the 
child downwards; but the attendant should always carefully reflect, 
while employing any extractive force, that the child's neck will not 
bear a great deal of pulling, without the most destructive effects on 
the spinal marrow. Certain it is that the infant in the birth will not 
safely bear more force applied to its neck than one after the birth, a 
reflection that ought to regulate the physician always. The infant 
will not safely bear a more violent pull by the neck in this situation, 
than it would if dressed and lying in its mother's arms. Such a 
reflection would be a very safe one for the occasion. 

If all his exhortations fail of causing the woman to assist him by 
bearing down, let him endeavor to preserve the child from suffocation 
by passing two of his fingers upwards until they reach the two max- 
illary bones, and cover the nose ; by doing this the backs of the 
fingers, pressing the perineum backwards, serve to keep an open com- 
munication with the air, and the child can breathe very well until the 
tenesmus comes on. I have kept a child alive in this way, breathing 
and sometimes crying, for twenty or twenty-five minutes before the 
birth of the head, and thereby saved a life that must have been lost 
but for this care. At last the head descends and escapes from the 
vulva very suddenly, after which, the placenta having been duly 
attended to, the delivery is complete; whereupon the patient may be 
put to bed. 

Second Position. — The rule for managing this case is the same as 
that for the first position. Here the sacrum of the child is to the right 
acetabulum of the mother. The right hip to her left acetabulum and 
the left one to her right sacro-iliac symphysis. As the presenting 
part descends the right hip comes to the pubis and the left falls into 
the curve of the sacrum. 

Third Position. — Here the sacrum of the child lies behind the 
pubal symphysis — its right trochanter to her left ischium, and its 
left trochanter to the right ischial plane. In any such case there 
will be rotation converting the case into one of the first or the second 



PELVIC PRESENTATIONS. 355 

position, as accident may determine. It requires no further observa- 
tion in this place. 

A few years ago I was engaged to attend a young woman in her 
first child-birth. When she fell in labor, I discovered that the breech 
presented. Her residence was about three-fourths of a mile from 
my house. I was very much inclined to send for my forceps, for 
fear that when the head should come at last to occupy the vagina, I 
might be unable speedily to deliver it. But as she was exceedingly 
delicate and timid, and her friends anxious, I deferred sending for 
them lest needless alarm should be the consequence of bringing them 
to the house. The labor proceeded very favorably until the shoulders 
were free, and then, notwithstanding the head took the most favorable 
position, I found that no exhortations or entreaties could suffice to 
make the woman bear down, and the child soon became threatened 
with asphyxia, which I obviated by admitting the air freely to its 
mouth and nostrils, by pressing off the perineum. The child cried, 
and 1 felt a hope that the forceps, which I now sent for, would arrive 
in time for its succor. The instruments were placed in my hands 
in the shortest time possible. In two minutes after I received them 
they were applied, and the head withdrawn, but it was too late to re- 
suscitate the child. I have never since failed to order my forceps to 
be placed within my reach in any case of footling or breech labor, 
and I feel well assured that the consequence of this care has been the 
saving of several lives that must have been lost but for this precau- 
tion. I have lost but one child in pelvic presentation in the last three 
years, and that was one which was a vertex case, but which I brought 
footling in consequence of hemorrhage from placenta prsevia, and in 
which I was obliged to deliver the head with the forceps, as the 
woman was so exhausted by loss of blood that she could not bear 
down. 

It is my unfailing custom to order a forceps to be got in readiness 
as soon as I ascertain that the presentation is not one of the head ; 
and I feel well assured that such a precaution, if generally observed, 
would preserve many a life that is now lost, either by delay in the 
delivery of the head, or by pernicious attempts to extract by pulling 
at the neck, to which the temptation is so strong in moments of great 
anxiety for both parent and offspring. 

It is so unpleasant an event in the practice of midwifery to lose a 
child in the operation, that the accoucheur ought to take all the 
precautions possible to free himself from reproach, which he shall 
scarcely escape, in consequence of the utter ignorance of the nature 



356 PELVIC PRESENTATIONS. 

of parturition even in what is called educated or good society. On 
the 11th September, 1848, I visited a primipara lady in labor, at 7 
A. Iff. She had been in sharp pain from 10 P. Iff., nine hours. The 
os uteri was not so large as the end of a finger. Upon ausculting 
and examining by palpation the uterus I determined a pelvic present- 
ation at 12 Iff. : I thought the labor would continue until morning, 
so slow was the dilatation, but at 5 the membranes gave way and 
all the liquor amnii came off, the os uteri being still rigid and irri- 
table. The bands of the upper os uteri were more tense and unyield- 
ing than those of the os tincae proper. The child was still in health, 
as ascertained by the regular action of the heart. I had announced 
all the hazard for the child early in the day. My forceps was :.: 
hand; at 8 P. M. the head was thrust into the vagina, and, as I 
failed to deliver it with my hands, I applied the forceps and speedily 
drew out the head. The child was quite dead. There was no 
motion of the heart. When I drew down the feet I found there 
no vital tension in the limbs. Now I feel sure that this child perished 
by asphyxia from the unmitigated pressure of its placenta against the 
head consequent to the discharge of the waters. It perished of course 
before the operation. Now, could I by any careful obstetrical 
measure have saved it ? I regretted, upon finding it dead, that I had 
not repeated my auscultations, after the crevasse of the ovum. Had I 
done so, I should have been able to announce the less 
of the child long before the midwifery operation be- 
came possible. I do not suppose that I am blamed by its friends, 
: it a young accoucheur would feel less uncomfortable in such a case 
for having announced his prognosis. Hence let the Student remember 
to auscult often towards ::.- :sr of pelvic labors. 

Fourth Position. — In those cases in which the sacrum of the child 
is t ed towards the mother's back, it is highly desirable so to con- 
duct the labor as to effect a complete rotation of the child by the time 
the head begins to get pretty low in the excavation. If this change 
does not take place spontaneously, or by the skillful interference of 
the accoucheur, it must happen, at the last and important stage, that 
the face will be to the pubis, and then there will be some difficulty 
in obtaining the requisite dip of the head or its due flexion. I: is 
exceedingly dangerous for the child to be so situated, but happily 
there is a method by which it may be hopefully assisted. 

As soon as the shoulders are fairly freed from the vulva, the edge 
of the perineum tends to compress the neck :: the child, and force it 



PELVIC PRESENTATIONS. 357 

upwards against the arch of the pubis. In some cases the perineum 
is so strong or elastic as to exert a considerable power in this way ; 
and it is clear that if it be not counteracted, the chin may be lodged 
upon the top of the symphysis of the pubis, and wholly prevent the 
flexion of the head from taking place. Under such circumstances 
the child will speedily perish. The indication is then to push the 
perineum back again, or carry the child far back towards the coccyx, 
and afford space enough to let the chin descend, either spontaneously 
or by pulling it down by introducing the fore and middle fingers of 
the right hand into the mouth. As soon as the chin is well brought 
down, the woman should use all her power to assist in the expulsion 
of the head. I have found that the best attitude for the mother, in 
this kind of delivery, is that which is advised for forceps operations, 
to w r it, that in which she is placed on her back, with the hips brought 
quite over the edge of the bed, the feet being supported by two as- 
sistants ; so that, when the shoulders are delivered, the child may 
be supported almost in a vertical posture by the left hand of the 
accoucheur, while his right hand aids in the delivery of the head. I 
am sure that much greater command of the labor may be had in this 
position of the patient than in any other that can be devised. 

But, as I have already observed, we should endeavor to manage the 
case so as to get the face into the hollow of the sacrum, instead of 
letting the chin come to the pubis. If, therefore, the breech sink 
into the excavation in this unfavorable manner, we should, by pres- 
sure with two or three fingers, endeavor to force that hip which is 
nearest the front towards the symphysis, and if w T e succeed in effect- 
ing its delivery in that position, we should, with a proper degree of 
force, continue to turn the forward hip more and more round, so as to 
bring the child's spine at least as far in front as the ramus of the 
ischium or pubis ; so that when the shoulders begin to enter, they 
may enter obliquely, and after they have passed down, the head may 
also enter obliquely, or at least transversely. For example, let the 
sacrum be towards the mother's back, the child's right hip will be on 
the right ischium of the mother. We might try to get the right hip 
towards the ramus of the ischium, then towards the ramus of the 
pubis, and, as it advances, cause it to emerge just under the arch. 
When fully emerged, the hip should be turned more and more to the 
left of the mother, so as to let the right shoulder enter the brim at the 
left acetabulum and escape under the arch, in doing which the child's 
face will enter near the left sacro-iliac symphysis, and at last slide 
into the hollow of the sacrum, as in a second position of the breech. 



358 PELVIC PRESENTATIONS. 

Where this desirable rotation cannot be gently effected in conse- 
quence of the grasping force of the womb holding the child's body 
tight during a pain, we ought to watch for an opportunity during the 
absence of a pain, to push the child's body upwards again as far as 
we conveniently can, and then draw it downwards, endeavoring, 
while pulling it downwards, to twist or rotate it in the manner that is 
required. 

If, on the other hand, we endeavor to bring the left hip to the pubis, 
we shall also get the left shoulder there; at last, compelling the face 
to enter at the right sacro-iliac symphysis, we shall terminate the 
labor in the first position of the breech. 

I shall here relate a case taken from my record book, which may 
serve to show the Student what a great rotation may be effected by 
the hand of the practitioner, in cases of the fourth position. 

Tuesday, October 5th, 1830. Mrs. J., a young woman in her first 
pregnancy, sent for me at eight o'clock P.M. The waters came off 
at five o'clock P. M. The os uteri, at my arrival, was almost com- 
pletely opened. I touched the breech and feet ; the toes were towards 
the left acetabulum. At a quarter before nine o'clock I disengaged 
the right foot, and then the left one. At nine the arms were both 
delivered, the left one escaping first along the perineum and the right 
one under the pubis. I could not effect any further rotation, and was 
sorry to find the chin immediately behind the symphysis pubis. I 
then turned the child's body, and pulling the chin well downwards, I 
pressed the face with two fingers, on its right side, and with great 
ease turned it into the hollow of the sacrum. I next made a channel 
by passing up two fingers to the superior maxilla so as to admit air 
freely to the nose, and the infant breathed ; there was a total cessa- 
tion of pulsation in the cord. The child breathed and cried at least 
for twenty minutes before the head was extracted, which I could not 
effect until I carried its body upwards towards the mother's abdomen, 
and rolled her over on her right side, which gave me far better power 
to aid her with my right hand. The infant was born living, and did 
well. I shall cite another instance which occurred very recently. 

On Thursday, July 14th, 1836, Mrs. was seized with labor 

pains, which came on with the rupture of the membranes. At six 
o'clock, I made an examination, and found the left foot in the vagina, 
accompanied by the umbilical cord, which pulsated. The toes were 
directed to the pubis. I could reach the breech of the child, but the 
right foot was so high up that I could not touch it. In a short time 
the left foot came quite down ; and in order to rotate the body I drew 



PELVIC PRESENTATIONS. 359 

moderately upon the foot, which caused the left hip rapidly to approach 
the pubis. I could not even yet get at the right foot, wherefore I per- 
mitted the child to descend with that limb pressed upwards against 
the belly ; the left hip came under the centre of the arch, and, as soon 
as I could command it, I turned it more and more round, so that 
when the arms w T ere delivered I found the face in the sacrum, soon 
after which the head was expelled. I immediately ascertained, that 
there was a second child ; pains came on, and in fifteen minutes after 
the first one was born, I broke the membranes of the second, which 
presented the nates and the right foot. The foot prolapsed, but the 
other limb was pressed against the child's belly, so that I could not 
get it ; the sacrum was to the right acetabulum. When the shoulders 
were delivered I found the child's face rather transversely directed 
towards the left ischium. I brought it into the hollow of the sacrum, 
soon after which it was also expelled. Both children are well. 

It is so easy a matter, in general, to cause the body to rotate during 
its transit through the pelvis, that it very rarely happens, if the phy- 
sician is called early, that the face at last is found towards the pubis. 

With regard to the presentations of the feet and knees, I do not feel 
that it is necessary for me to enlarge upon them, before I close this 
chapter, inasmuch as the footling case is a mere accident happening 
in a pelvic presentation, and which, moreover, can never prevent it 
from being at last a pelvic presentation — for all footling and knee 
cases are certainly breech presentations. I may remark, however, 
that the knee presentation is found to be embarrassing from the tend- 
ency there is to a sort of arrest, in consequence of the knees abut- 
ting against the sides or parietes of the pelvis, which is sufficient to 
prevent the descent of the child's nates, so that they, being thereby 
thrust over to the opposite side, cannot enter the excavation. Hence, 
where the knees present, it is advisable to convert it into a footling 
case, which can be done by pushing the whole presentation upwards, 
during the absence of pain, in order to gain space enough to bring 
down the feet. 

The Student will perceive, if he refers to the axis of the womb and 
that of the vagina, that in a knee case, in which the child's back is 
towards the left front of the mother, the thighs would be very greatly 
extended, or bent backwards, before they could emerge from the ex- 
ternal organs ; an extension that must be very difficult to effect where 
the legs are bent up on the back of the thighs — for in such circum- 
stances the rectus femoris, and indeed the whole quadriceps muscle 
must be put excessively on the stretch. It is a good rule, therefore, 



360 PELVIC PRESENTATIONS. 

in knee presentations, to get the feet down as soon as it can be pru- 
dently done; whereas in the well defined breech cases, the feet ought 
not to be brought down, except for some valid and well understood 
cause. 

In order to distinguish the feet from the hands, for which they are 
sometimes mistaken, it is only necessary to give attention to the sen- 
sations imparted by the operation of Touching. The even range of the 
ends of the toes, and their shortness, compared with the length of the 
fingers ; the closeness of the great toe to the one next to it, in contrast 
with the wide separation of the thumb from the fore finger; the ankle, 
and the heel, are marks that might be supposed sufficiently prominent 
to guard us against even the danger of mistake ; yet, very great atten- 
tion is in some instances required, to enable us to aver positively that 
the presenting part is, or is not the foot. 

As the footling is but a deviation from the breech presentation, its 
positions are like its original form ; namely, the heels to the left ace- 
tabulum ; the heels to the right acetabulum; the heels to the pubis ; 
and lastly the heels to the sacrum. As the treatment is precisely the 
same as in presentations of the nates, I shall not detain the reader by 
any further remarks upon the management of them. 



PRETERNATURAL LABOR. 361 



CHAPTER XIII 



OF PRETERNATURAL LABOR. 



Any labor that cannot be brought to a safe conclusion by the 
natural powers of the system might properly be denominated a pre- 
ternatural labor; and as the causes that might prevent the accom- 
plishment of the parturition save by the intervention of our art, are 
very numerous, it follows that there are a great many kinds of pre- 
ternatural labor. 

Causes. — A labor may be accidentally changed from a natural to 
a preternatural one; or it may possess a preternatural character from 
the very beginning, and be unavoidably so. Thus, a woman may 
have brought her child almost into the world without any appearance 
of disorder or danger or uncommon distress, and be then suddenly 
attacked with convulsions, apoplexy, hemorrhage or laceration of the 
womb, &c. &c, either of which occurrences completely changes the 
character of the labor. Or, she may, in consequence of disease or 
accident, be found incapable of bringing her child into the light 
without surgical aid; as, where the passages are closed by stric- 
ture, or by some fibrous tumor, or by a deformity of the bones of the 
pelvis. Lastly, the labor may be preternatural because there pre- 
sents at the strait some portion of the child which cannot pass through 
it, but must be put aside in order to let some other part advance, 
before the labor can be brought to a close. For example, if the 
arm or shoulder should present, it is necessary to put them out of the 
way and bring the head back to the opening, or else the feet must 
be brought there, the child being for that purpose turned quite over; 
for have we not learned that one or the other of the extremities of the 
fcetal ovoid must advance, in order to admit of the escape of the child? 

It appears from the above that the causes which constitute preter- 
natural labor are very various; and it is reasonable to infer that the 
medical and obstetric treatment of the several cases will be founded 



362 



PRETERNATURAL LABOR. 



upon the peculiar and distinguishing character of each individual 
example of the labors. The subject, therefore, embraces so wide a 
field of discussion and detail, that it will be requisite to treat it according 
to the nature of the several causes that happen to interfere with the 
usual process of child-birth, and I shall endeavor to describe the 
different sorts of preternatural labor according to the circumstances 
which make them what they are, and point out the modes of treatment 
most suitable to their several natures. Before entering fully upon 
the subject I think it advisable to lay before the Student a tabular 
view of a great number of labors that were observed and recorded 
under the direction of the late Madame Lachapelle of the Maternite 
Hospital at Paris. I wish the Student to look over this table in order 
to see what was the frequency of different sorts of labors in that 
series which is here tabulated by that distinguished person in her 
work. — There were observed 22,243 labors, of which 15,809 were 
first positions of the vertex, &c. &c. 



Comparative Statemen t of the Different Positions observed from Jan. 1, IS 12, to Dec. 31, 1820 
(Nine Years'), by Madame Lachapelle. 



Positions. 


o 


to 

lb 


■ - b 


a5 
"3 


J5 
<2 






o 




H 


S3 ""^ 


2 > 


HJ 


TD 


— -a 


T2 


o~£ 






o S, 












'5 o 






c^ 








JS o 


^3 


ci ~ 






m 


< 


Q 


o 


u 


O 


<A 


1st. Vertex • ' 


15,809 


15,728 


81 


14,963 


335 


18 


493 


4 nearlv. 


2d. Vertex 


4.659 


4,628 


31 


4,372 


123 


4 


160 


1+1 " 


4 th. Vertex 


164 


151 


13 


126 


26 


1 


11 


f i 3 a 


5 th. Vertex 
3d. Face 


66 
58 


60 
51 


6 
7 


56 
50 


6 
6 




4 
2 \ 


4th. Face 


45 


37 


8 


34 


7 


1 


3 I 


1 -1- 9S L 


1st. Breech 


294 


287 


7 


210 


36 


10 


38' 




2d. Breech 


191 


189 


2 


147 


23 


2 


19 




3d. Breech 


3 


3 




1 




1 


1 




4th. Breech 


4 


4 




3 






1 




1st. Feet 


215 


212 


3 


159 


27 


1 


28 




2d. Feet 


84 


82 


2 


52 


14 


2 


16 


> 2T^8 4 


3d. Feet 
















4th. Feet 


4 


4 




4 










1st. Knees 


6 


6 




4 


1 




1 




2d. Knees 


3 


3 




1 


1 




1 




3d. Knees 


















4th. Knees 


















3d. Right shoulder 


41 


8 


33 


20 


5 


6 


10< 

7 




4th. Right shoulder 


24 


3 


21 


11 


3 


3 


>Th+T 5 A 


3d. Left shoulder 


19 


1 


18 


9 


2 


1 




4th. Left shoulder 


34 




34 


23 


7 




4 




Unascertained 


520 


517 


3 


39S 


11 


80 


31 




Total 


22,243 


21,975 


268 


3 20.64 


633 


130 


837 





PRETERNATURAL LABOR. 363 

Perhaps it matters not which kind of preternatural labor is here 
first treated of, for there is no natural order or method of their oc- 
currence; each one might be the subject of a separate monograph. 
Yet I have chosen to commence with the account of presentations of 
the shoulder, in which the operation of Turning is generally consi- 
dered to be inevitable as a part of the treatment ; and since that ope- 
ration is not unfrequently resorted to in other specimens of preterna- 
tural labor, I deem it of some advantage to take an early opportunity 
of describing it in this connection. 

I have already said that, in order to constitute a natural labor, one 
of the extremities of the foetal ovoid ought to present at the opening; 
and I have treated of the pelvic presentations as being natural ; and 
I have supposed that the knee and footling cases are but accidents or 
deviations of the natural pelvic presentation. 

In presentations of the head there is also, I said, a liability to de- 
viations, by which the head glances off from the brim of the pelvis, 
and is either turned upwards into the costa of the ilium, or rises above 
the top of the pubis. 

In a case where the direction of the uterus is very oblique, so as 
to allow the fundus to fall far down into the right flank of the patient, 
the child, if pressed by the contractions of the fundus, might be pushed 
towards the left side of the brim of the pelvis in such a manner as to 
make it doubtful whether the head would enter the strait, or slide 
upwards on the left side of the womb. For the most part, it fortu- 
nately happens, even in the very greatest lateral obliquity of the 
womb, that the head is not deflected, but enters the strait; but in a 
few examples it is found to rise upwards, instead of engaging. When 
this takes place, it must almost inevitably happen for the shoulder to 
fall into the cavity from which the head was turned away, and as the 
shoulder is a projecting part it is very liable to maintain the position 
in which it is once ensconced. The shoulder, therefore, when the 
head glances off, descends or engages in the superior strait, and is 
pushed downwards by the uterine contractions as far as it can pos- 
sibly be urged, and then it stops. The strait being jammed full of 
a mass, composed of the shoulder, arm, neck, throat and part of the 
thorax of the child; and when no additional portions of the child can 
be pressed into it, a total arrest of the progress takes place, and the 
woman, after vain struggles, protracted according to the strength of 
her constitution, sinks at last, without the possibility of rescue from 
death except by the skillful aid of the obstetrician. 

There can scarcely be any need for me to enlarge upon the im- 



364 PRETERNATURAL LABOR. 

practicability of delivery here except by art; for even could the 
shoulder be pushed down as low as the vulva, it would happen, at 
last, that the head would be again brought to the strait from which it 
had been turned off, but it would be accompanied by the child's body, 
either of which, alone, is sufficient to fill the plane and the excava- 
tion, so that the two together could by no means pass through. The 
remedy is either to push the shoulder out of the way and to bring the 
child's feet down so as to deliver it footling, or to restore the head to 
its proper place. There is, even where the operation is impracti- 
cable, an exceptional escape from death under these circumstances 
by the very rare occurrence of what is called spontaneous evolution 
of the foetus, to be hereafter described. 

I ought to remark that while the shoulder presentation is a deviation 
or accident occurring in an original head presentation, so it may hap- 
pen that, instead of the shoulder, the hand or elbow may come down, 
but in fact they are mere circumstances of a shoulder case, and when 
they are advanced to a certain degree, it is the shoulder, after all, 
that fills the strait and the excavation, and which constitutes the pre- 
sentation. The hand and arm are merely prolapsed, ana their pro- 
lapsion adds nothing to the difficulty of the case ; indeed, their prolap- 
sion serves as a means of guiding us in our diagnosis, and does not 
at all oppose the successful treatment of the labor. In the manage- 
ment of a pelvic presentation I should, in general, prefer that the feet 
should not prolapse ; in a shoulder presentation it would be rather a 
favorable circumstance for the arm to prolapse. 

Case. — Some months since I was in attendance in a labor case, in 
which, though the os uteri was very much dilated, and completely 
dilatable and distended with the bag of waters, I could not with the 
index finger touch the presentation. The patient was very much 
flexed, which relaxed her abdominal integuments. Upon placing 
my hand over the right iliacus muscle, I distinctly felt the orbicular 
mass of the child's head under my palm. Introducing the fingers 
again, I waited until a pain came on. As soon as the bag of waters 
became tense from the pain, I pressed, with my left hand, the head 
out of the right iliac fossa towards the chasm of the superior strait. 
I then ruptured the ovum, and exhorting the woman to " bear down, 
bear down," I had the pleasure to find the head driven quite into the 
excavation, and to find it born after a few minutes. Doubtless I pre- 
vented the shoulder from coming to the os uteri by pushing the head 
to it. 



PRETERNATURAL LABOR. 



365 



Fig. 82. 



Two Shoulder Presentations. — Two Positions for each Shoul- 
der. — As there are two shoulders, a right and a left one, there must 
be a set of positions for each shoulder; but in determining what is 
the position of the shoulder, it is also necessary to determine the situ- 
ation of the child's head. In speaking of natural labor with the 
vertex in the first position, I endeavored to explain the causes which 
give a greater number of first positions. The same reasons operate 
to produce, in shoulder presentations, a greater proportion of instances 
in which the head is to the left side of the pelvis, than those in which 
it is to the right side. Now if the right shoulder presents at the strait 
and the head is to the left, as in Fig. 82, the 
face of the child, and its toes and feet will 
look towards the mother's back; but if the 
same shoulder presents and the head is to 
the right side of the pelvis, the face and front 
of the child must look towards the mother's 
front: so of the left shoulder in the first posi- 
tion, the face will look in front, and in the 
second position it will look towards the mo- 
ther's back. By speaking therefore of the posi- 
tions of the two shoulders separately, we get 
a better and less complex idea of this sort of 
labor than we should have were we to enume- 
rate a set of positions without such a division. 

I think that the form of the foetus and the capacity of the womb 
are such as to make it unnecessary to establish more than two positions 
for each shoulder: for example, for the right shoulder a first position, 
or that in which the head is to the left, looking backwards, and a 
second in which the head is to the right, and looking front ; for the 
left shoulder a first position, wherein the head is to the left, looking 
front, and a second in which it is to the right, looking towards the 
back of the mother. This will, I think, be quite sufficient; and gives 
us four positions for the shoulders, hand or elbow. It is not to be 
denied that the head might be in front, looking to the left or looking 
to the right side of the mother, giving us in the former case a right 
shoulder, and in the latter a left one, in the strait; but it is needless 
to enumerate such a position, as the contractions of the womb and 
abdominal muscles would soon turn it into one of the attitudes I have 
before pointed out. 




Diagnosis. — The signs by which a shoulder at the strait may be 



366 PRETERNATURAL LABOR. 

diagnosed, are, 1. The want of the regular form of the bag of waters, 
which in all preternatural presentations is without that proper convex 
shape that we notice in favorable instances of natural labor. When 
the membranes pass down into the vagina shaped almost like an in- 
testine or of a cylindrical form, there is good reason to think there is 
something untoward in the posture of the infant. 2. The spinous 
process of the scapula; the clavicle; the round-shaped shoulder; the 
axilla; the ribs; the arm, distinguishable by its size from the thigh. 
Should the attendant retain any doubts, let him never omit to remove 
those doubts by the introduction of his hand into the vagina, where 
he will be able freely to examine the nature of the presenting part, 
and learn its true position.' No person is excusable for mistaking the 
diagnosis who knows he can command so infallible a method of making 
a correct one. The diagnosis can always be made in good time, — 
that is, as soon as the dilatation will admit, and until then nothing 
can be done. 

Turning.-— Having ascertained that a shoulder is at the strait, 
there remains but one determination for the practitioner, and that is 
to put it away and bring another part of the child to present. This 
necessity, and the hazard in which, consequently, both the mother 
and child are involved, should be plainly and seriously laid before 
those who have the best right to know her case ; namely, her hus- 
band or parents, or such near relatives or friends as may seem to be, 
for the time, in loco parentis for her. The necessity for interference 
ought also to be explained to the sufferer herself, but in the gentlest 
and most cheering manner possible. If it be within the bounds of 
possibility to do so in good time, a medical brother ought to be in- 
vited in order that his counsel may be taken, and particularly that 
the friends, and the patient also, may have no doubt left in their 
minds as to the propriety of the operation, nor claim the least right 
to find fault afterwards with the physician, should any untoward event 
follow the plan he had recommended. The act of turning to deliver 
by the feet is fraught with danger, for there is danger* of uterine lace- 
ration or of fatal contusions of the parts of the mother and of failure 
to succeed in effecting the version and great danger of destroying the 
life of the child in the act of turning. In early times, our ancestors 
who did not understand the mechanism of labor used to wait, after 
pushing the shoulder back into the body, in hopes the head might 
descend. For example here is the doctrine of Thomas Rainold, to be 
found at fol. 65 of his Woman's Booke : " And yf so be that it appears 



PRETERNATURAL LABOR. 367 

and comes forth first the shoulders, as in the XI figure, then muste 
ye fayre and softlye thruste it backe again by the shoulders till suche 
tyme as the head comeforwarde." It may be that those old practitioners 
of the days of Queen Elizabeth, may have sometimes succeeded by 
pushing up the presenting shoulder in getting the head at last to come 
to the strait again; but such an event appears to me in any case 
most improbable. 

But no operation can be performed while the os uteri is so closed 
as to refuse admittance to the hand. It cannot, and must not, be 
forced. The mouth of the womb must be dilated or dilatable before 
any operation is lawful ; it must be dilated or sufficiently yielding to 
allow the hand to pass upwards into the uterine cavity ; of this degree 
of dilatability the obstetrician is the only judge. He must never run 
the risk of tearing such an important organ, since its laceration by 
his hand would be much increased by the following birth of the child, 
and place the woman in danger of sudden death ; or he might con- 
tuse the parts so much as to establish a very dangerous inflammation of 
the organ. So important is it to judge aright concerning the time to 
be chosen for the exploration of the womb, that it is thought to be 
the most responsible duty of the physician in the whole case. If he 
proceed too soon, the most lamentable consequences are apt to ensue; 
and if he defer the procedure too long, the difficulties and dangers 
are greatly enhanced by the delay, while the patient also suffers use- 
less and pernicious pain. The bladder and rectum should be evacu- 
ated before the operation. The position should be carefully ascer- 
tained ; this can be done by the introduction of the hand, if necessary, 
into the vagina; and if it be certain that the left shoulder presents 
with the head on the left side of the womb, then he must make choice 
of that hand which can most conveniently be employed in the opera- 
tion. The rule is to use that hand whose palm, when open in the 
cavity of the w T omb, would look towards the face or breast or belly of 
the child, which, in this instance, would be the right hand ; for it is 
clear that if the left hand were used, it would not apply the palm to 
the front of the infant, whether it were carried up before or behind 
the child's body. 

The best position for the patient is that on the back, with the end 
of the sacrum brought quite over the edge of the bed, the feet and 
knees being carefully supported by assistants, one holding each limb, 
which should be properly flexed. The woman ought*to be carefully 
covered with a sheet or a light blanket, according to the season of the 
year, and some thick cloths should be placed on the floor, under the 



368 PRETERNATURAL LABOR. 

foot of the bed, to receive any discharges of water or blood that might 
accompany the operation. 

Everything being fully prepared, the operator's arm should be bared 
to the elbow, and well anointed with lard, while a sufficient quantity 
of the same material should be applied to the external parts. During 
a pain, two fingers, and then three, of the left hand, should be passed 
into the vagina, to be followed by the little finger, and afterwards by 
the thumb, strongly flexed into the palm. The hand having gained 
possession of the vagina, may then rest until the pain is gone off, after 
which the presenting part must be pushed upwards and leftwards, the 
fingers and whole hand, in pronation, following the receding shoulder 
into the cavity of the womb. The shoulder being moved somewhat to 
the left as it mounts upwards, when the hand is fairly introduced it 
ought to be opened and glided along the breast or abdomen towards the 
feet or knees of the fcetus, which will be looked for on the right and 
superior portion of the cavity. In searching for the feet, the contrac- 
tions of the womb are excited, and pains are produced, especially if 
the waters are much drained off. During these contractions it is ab- 
solutely necessary to open the hand, lest the uterus, from the violence 
of its own action, might be torn on the knuckles ; and the hand ought 
never to move except the organ be in a state of relaxation. At length, 
after more or less research, one or both feet, or a knee is found, and 
whether it be one or the other, it should be taken hold of; for it is 
nearly a matter of indifference whether it be one foot or both, or one 
knee that is used as the point on which to act in turning the child. 
Dr. Collins, p. 69, remarks on this point that, "it is quite sufficient to 
bring down one foot," and I find that Dr. Simpson of Edinburgh is 
of the same opinion — deeming it far more injurious to make perverse 
attempts at exploration, than to deliver by one foot only. I say nearly 
a matter of indifference, because, the object being to turn the child 
as soon as practicable, with proper caution it may be effected in either 
of these ways : it is always desirable to get the hand out of the uterus 
as soon as may be, and it is far better to turn by one foot or by a 
knee, than to incur the risk of laceration or contusions of the organ, 
by a tedious search after the other foot, which, if it be not originally 
near its fellow, is very hard to be found by any search for it. The 
inexperienced student can have little notion of the extreme difficulty 
there is to move the hand about while it is compressed betwixt the 
womb and the Thild ; a short experiment of this difficulty would suffice 
to convince him of the propriety of the foregoing directions. If he 
should use the knee as a point of traction, it would be very easy, 



PRETERNATURAL LABOR. 369 

when the version is nearly complete, to draw the foot down. If he 
use only one foot to turn by, he will have nearly all the proposed 
advantage of the breech presentation combined with the greater 
facility enjoyed in manipulating in the footling case — that is to say, 
he will have the abundant dilatation, and the power of traction by 
the limb. 

Having found the foot, if a pain comes on immediately, and be- 
comes a severe one, the foot should be let go, and caught again after 
the pain is gone off, according to the discretion of the operator. 
During all the time he is passing his hand up and exploring for the 
child, either his own unoccupied hand or that of an assistant should 
be applied to the abdomen, in order, by pressing the womb down- 
wards, to keep the os uteri within the strait ; and when he is ready 
to turn the child, his own hand only should be used by the operator 
to press on the outside of the abdomen, so as to favor the version by 
pushing the breech of the child downwards, while he also draw T s it 
downwards by the feet or knees. If the hand ought not to move 
during a pain, it w r ould, a fortiori, be the height of rashness to attempt 
to turn the child with the womb in a state of contraction. The time 
for turning ought to be chosen as soon as the pain has gone off. Then 
the womb feels yielding and soft as a wet bladder, and the part held 
in the hand may be drawn towards the os uteri slowly and gently, 
but firmly, and, if possible, brought quite into the vagina, or even to 
the vulva. External pressure with the free hand favors this version 
very considerably, and ought never to be neglected. 

It is easy to ascertain if the version be complete by external taxis, 
and by noticing how far the child is drawn downwards, and judging 
of its length as compared with the length of the uterus, as well as by 
noting the effect of the next pain, which propels it if it be turned, but 
does not move it if it be still transversely fixed in utero. 

The Student should remember that the child from the extremity of 
the buttock to the crown of the head is between eleven and twelve 
inches in length. Hence his hand placed on the abdomen will inform 
him whether the uterus is of this length or no. If he find the buttock 
at the os uteri and the uterus not so long as it should be under the 
circumstances, he will know that the version is not yet completed, 
and take his measures accordingly. 

Wherever it is possible to make choice of a foot to pull on, w T e 

should select that which is nearest the front of the pelvis. In the 

present case it would be the right foot, because in drawing upon that 

one, the right hip would come under the pubic arch, and favor very 

2i 



370 PRETERNATURAL LABOR. 

decidedly our wish to bring the vertex at last to the pubis, and carry 
the face to the hollow of the sacrum ; whereas, should we draw down 
upon the left foot, the child's face would, at last, be very sure to come 
to the pubis. 

Under all circumstances the practitioner is only called upon to do 
that which he can do, and not that which he would but cannot da; 
therefore when he can only find the most unfavorable foot let him draw 
by it and meet the consequences. 

As soon as the turning is complete, the case has become a footling 
one, and must be treated as if it were originally so ; that is, it should 
be left to the expulsive powers alone, if they are sufficient, for it is 
always bad and almost always unnecessary to draw out the body ; it 
should be expelled by the pains. The arms must receive such assist- 
ance as they may need ; and the head, being properly situated in the 
vagina, ought to be expelled by the womb with such aid, from slight 
tractions, as the obstetrician may adventure with safety to make. 

In going about to perform this operation, the medical attendant 
ought to reflect upon all the dangers incident to it, and clearly under- 
stand, beforehand, that what is most desired in it is, not speed, but 
safety ; festina lente ought to be the motto. As to the difficulties of 
it, they are so great, in a womb long drained of its waters and lashed 
into fury by a long period of unavailing irritation suffered previously 
to the operation, that nothing but practical experience of them can 
make them known, unless indeed the fact be understood that it can- 
not, in some instances, be effected at all, and that we are obliged to 
extract the child double, after having removed the thoracic viscera, as 
well as those of the abdomen, by the crotchet and perforator ; upon 
doing which the foetal remains may be drawn forth. 

I have, after having had my hand in the womb, found it so com- 
pletely benumbed by the pressure, as to be unable to feel with it or to 
close it; in such a case, the other ought to be made use of, however 
ill adapted either for the exploration or seizing the feet, &c. 

The child being delivered, the mother must be drawn up into her 
bed, so as to enable her to stretch out her feet, and as soon as the 
placenta is taken away, she should be bandaged and put to bed 
properly. A grain of opium, or a dose of laudanum consisting of 
twenty or forty drops, is very soothing and calming, after such high 
excitement and fatigue, and ought not to be withheld from her. 
A cup of tea or gruel may next be presented to her, and a short sleep, 
if she can take it, is followed by a comfortable state, for the before 
exhausted woman. 



PRETERNATURAL LABOR. 371 

There is very little difficulty in this operation, if the waters are 
not gone off; they should, therefore, be always left whole if possible 
until the moment for the interference is at hand. Could we, indeed, 
always have the privilege of rupturing the ovum at the time of carry- 
ing the hand into the womb, we should avoid much difficulty, and a 
large moiety of the danger of doing mischief. Unfortunately, how- 
ever, turning is rarely determined on until the waters are lost, and 
then the danger is necessarily greater. 

There are many very ignorant persons, who are generally the more 
presumptuous the more they lack knowledge, into whose hands 
women are so unhappy as to fall on the occasion of their child-birth. 
If, in a shoulder presentation, the hand happens to prolapse, they, 
finding a very convenient handle, make use of it to pull the child 
away by; and I have seen a case in which an unfortunate woman 
had been so treated: the arm was wholly withdrawn, and the acro- 
mion process of the scapula was actually under the pubic arch ; so 
violent were the tractions that had been made on the hand and arm. 
This was done too with a rigid os uteri, which, after yielding a reluc- 
tant passage for the arm and point of the shoulder, was now grasping 
the parts above it with a strength like that of a rope, and which after- 
wards resisted, for a long time, all attempts to pass the hand along 
betwixt its circle and the child. 

To one unaccustomed to the incidents of the lying-in chamber, it 
would be, perhaps, vain to attempt to convey an idea of the resist- 
ance sometimes met with in the circle of the os uteri. Dr. Collins in 
speaking of one of his cases in Dublin Hospital says, at p. 67, "The 
mouth of the womb was absolutely as firm as a piece of thick leather, 
and embraced the arm of the child as tightly as a ligature could be 
applied without cutting the part." 

There cannot happen anything but evil from pulling at the hand 
and arm. Such force cannot pull the child down, for it is too large 
to pass doubled. The arm, actually, is not in the way; for the hand 
of a practitioner and the arm of a foetus at term, can never equal in 
size a circle sufficiently large for the head to pass through it. The 
lack of space is not in the faulty construction of the pelvis, but in the 
rigid constriction of the os uteri and vagina, which, if too rigid to 
admit the hand, is also too much so to allow the child to escape. That 
rigidity can be overcome. It cannot be needful to excise the arm, 
or twist it off at the shoulder joint, a horrid practice, which seems to 
have received a salutary check from a judicial investigation, that was 
had a few years since in France : a practitioner there, finding it im- 



372 PRETERNATURAL LABOR. 

possible for him to deliver in an arm presentation, cut it of! at the 
shoulder joint, and nevertheless the child was born alive. The ob- 
stetrician was justly prosecuted on a charge for maiming. 

If the os uteri will not admit the hand of the accoucheur, it is be- 
cause it is not dilated or dilatable. Let the proper measures, then, 
for effecting the requisite change in the uterine tension be resorted 
to. These are bleeding ; the warm bath ; antimonials ; emollient 
enemata, followed by enemata of laudanum; and patience, though 
last, not the least of the resources for such an occasion. Women in 
labor bear venesection remarkably well; and they demand, in some 
instances, very great abstractions of blood in order to get the full 
benefit of the relaxing efficacy of that remedy. A patient bled ad 
deliquium animi will be more capable of undergoing safely the ope- 
ration of turning, than one left to the unmitigated excitement of use- 
less labor pains. 

It will have been seen that in a preceding page I have strongly 
expressed my dissent as to the anaesthetic practice in midwifery. If 
there could be a case to render a complete anaesthesia by ether or 
chloroform a desirable condition for the patient and the practitioner, 
this is the case par excellence; certainly a complete anaesthesia might 
have the effect to abolish the voluntary power of the mother, and thus 
taking away the injurious force of the abdominal muscles and 
diaphragm, leave her to the sole influences of the uterine powers 
which are not annulled even by the deepest chloroformal insensibility. 
Professor Simpson and other distinguished gentlemen warmly advo- 
cate the induction of anaesthesia in these cases ; let the Student give 
heed to the opinions of these meritorious men, but let him be the sole 
judge of his own duty in any and in every case. 

The warm bath is a safe and easy remedy for the obstinate con- 
striction of the orifice, as it is for all spasms and other congenerous 
disorders. Tartar emetic, in doses of the eighth or sixteenth part of 
a grain, repeated every thirty or forty minutes, conduces very power- 
fully to the reduction of the spasm or rigidity, and it may be very 
safely resorted to in the management of our case. Much reliance is 
also to be placed on the power of the belladonna ointment applied to 
the cervix uteri, in which it often most speedily induces a complete 
local anaesthesia. Copious enemata of infusion of flaxseed, with a 
portion of castor oil to render it somewhat more aperient, should be 
had recourse to, and they may be followed by anodyne enemata, 
composed of an ounce of flaxseed tea or starch, with from fifty to 
eighty or one hundred drops of laudanum. We should also not for- 



PRETERNATURAL LABOR. 373 

get that patience ought to work her perfect work, and no more: the 
accoucheur must be the sole judge of how far patience ought to go. 

I should think that there can never be the least use in attempting 
to return the arm. The arm will be withdrawn by the version of the 
child. It goes upwards into the womb as the head rises and the 
breech descends. It would be always prudent to secure it by a noose, 
for the purpose of preventing its going too high within the cavity, 
where its presence might cause some embarrassment in the delivery 
of the head. 

P. Cosgreave, Esq., in the Lancet of 1828-9, p. 298, informs us, 
however, that he has never lost a child in an arm presentation. His 
method is to push up the arm during the absence of the pain, and 
return it into the womb and hold it there ; after which the spontaneous 
evolution takes place, and the infant is born by the spontaneous 
powers of the womb. Mr. C. must certainly be regarded as a very 
fortunate practitioner, to have met only with cases in which he could 
restore the arm to the cavity in this way, or in other words turn the 
child without searching for the feet. I am not aware of the number 
of his cases. I cannot therefore judge of the comparative success. 

Some persons have imagined that in the conduct of some of these 
dreadful cases of shoulder presentations, great facility in delivering 
the woman is obtained by amputating the arm, or wrenching or 
twisting it off by sheer brute force. Indeed I am aware of an instance 
in which the doctor tore off in utero, the arm of a child which was 
afterwards born alive, with the end of the humerus projecting below 
the ragged and torn edges of the wound. The arm was hidden, but 
afterwards discovered. The people interested were made to believe 
that the lost arm had been destroyed by absorption. 

Such a course of proceeding is to the last degree unjustifiable. 
Unjustifiable before the outraged family, and unjustifiable as bringing 
unmerited discredit upon the whole profession of physic. If in any 
case it were deemed necessary to remove the prolapsed arm, it ought 
not to be done without an antecedent announcement of the purpose, 
and its motives. For my own part, I cannot understand what are the 
motives should lead an accoucheur to do so barbarous an act. 

The extirpation cannot be deemed needful to provide space in a 
pelvis, since the arm of a fcetus can never fill up a pelvis so as to 
prevent the introduction of the accoucheur's hand for exploration and 
version. Whenever it is done, it is done with a view to make space 
in soft parts, but those soft parts will dilate in due time, and under 
wise treatment. My clear opinion is that the amputation of the arm 



374 PRETERNATURAL LABOR. 

in shoulder presentations is a mala-praxis, and that it ought to be 
discountenanced and protested against. 

Spontaneous Evolution of the Fcetus. — It has happened that 
the operator being unable to turn the child, was compelled to abandon 
any further and useless attempts to deliver. In such instances, the 
woman sometimes delivers herself by what is called spontaneous 
evolution of the fcetus. 

It is very important for the Student to understand clearly what is 
meant by spontaneous evolution of the child, and it will not be diffi- 
cult for him to do so, if he will bear in mind the fact : 1st, that there 
is a superior strait, and 2d, that the child's head and its body cannot 
be within the plane of that strait at the same time. 

Now when the shoulder has presented, and the arm fallen down, 
has allowed the shoulder to be forced, or drawn quite out underneath 
the triangular ligament of the pubis, it happens that the side of the 
child's neck lies against the inner aspect of the symphysis of the pubis. 
But, if the side of the neck is pressed against the wall of the symphysis, 
the head of the child will lie upon, and even project over and beyond 
the horizontal part of the pubal bone, making a hard orbicular tumor 
that may be felt there with the hand, if it be laid on the hypogaster. 

Now, things being situated as above, let the Student conceive that 
the trunk of the child's body still contained in the womb, is thrust by 
the continued contractions more and more downwards, the head rest- 
ing upon or beyond the brim. The effect of this downward thrusting 
force will be to push the shoulder farther and farther out beyond the 
crown of the arch, and the head more and more over the top of the 
bone, leaving a space in which to thrust the trunk of the child. If it 
be a left shoulder case in the second position, the third rib will come 
out at the vulva, then the fourth, fifth, sixth, seventh, and so on until 
all the left side of the thorax is pushed out, after which follows the 
left flank, the left ischium, and trochanter; upon the escape of which 
the left thigh and leg are delivered, followed immediately by the right 
thigh and leg, then the right arm, w T hereupon nothing remains but 
the head, which is speedily born. 

Such is a spontaneous evolution. It differs from Version or Turning 
in this — that in turning the head goes up to the fundus, while the 
buttock comes into the passage. Here the head is held close to the 
plane of the strait, by the shoulder which has got under the arch, and 
even projects beyond it, so that the head is, as it were, tied fast to 
the brim so it cannot rise. 

Here I repeat the figure of the double headed fcetus, which I already 



PRETERNATURAL LABOR. 



375 



Fig. 83. 



have given at page 189, Fig. 61. Let the Student see in this 

figure a case in which evolution was 

indispensable. For example, suppose 

the right head to have presented, and 

to be delivered. That head would be 

held close to the vulva by the left head 

and body — the left head and body could 

not possibly be in the plane of the 

strait at the same time. It would be 

impossible to deliver by Turning — for 

the delivered head ties the undelivered 

one to the plane of the superior strait. 

Of course then it only remains that the 

undelivered head shall be forced over the 

horizontal ramus of the pubis to allow the 

trunk to descend by evolution, as I have 

described that process in the shoulder 

case. As soon as the trunk is born, the 

remaining head may be brought away. 

Dr. PfeifFer, who showed me the spe- 
cimen, delivered the woman, as I found 
upon inquiry, by compelling the evolution of the body of the fetus. 

Here is a repetition of the figure of Dr. Rohrer's case, given at p. 

Fig. 84. 





376 PRETERNATURAL LABOR. 

190. Let the Student observe, that such a vast fluctuating tumor on 
the vertex of the child, could never be the really presenting part; 
that it must necessarily deviate, and go up in the iliac fossa, allowing 
the true head to present, and making that, of course, a face presenta- 
tion. I say, of course, for the head would be of course in extension. 
Well, — the labor going on, — the head is born in face presentation, — 
giving the face the appearance of suggillation — of which I have made 
a good representation in the figure; but the head being born, the tu- 
mor, larger than the head, remains above the strait, in the same way 
as the second head of the double headed foetus of Dr. PfeifTer's did. 
Here, then, is a case in which evolution is indispensable, and Dr. 
Rohrer informed me that this was w T hat he brought about, — after doing 
which he was enabled, with very violent force of traction, to pull 
away the caput succedaneum — as you see it in the figure. 

I was called some time since by a friend of mine to assist him in 
a case of difficult and alarming labor. The woman was small, feeble, 
and highly nervous, the mother of several children. 

The doctor, finding the labor very slow, had administered a dose of 
ergot, which had brought on a most violent ergotism, to that degree, 
indeed, that I had great reason to fear she might speedily die from 
the mere excess of pain and irritation, if not from laceration of the 
womb, which appeared to me imminent. I have rarely witnessed a 
wilder expression of agony than here. 

I found the left shoulder down, in the second position. The indica- 
tion was to turn and deliver by the feet — which I was requested to 
attempt. Protesting beforehand that I deemed success impossible, I 
reluctantly consented to make an attempt. With great difficulty I 
passed my right hand through the os uteri; but it was completely pin- 
ioned and held fast and immovable by the muscular contraction, and 
I was but too happy to extract it without having caused a laceration 
of the cervix. The waters had long gone off. The child was dead. 
I concluded it was impossible to turn, and I felt equally concerned 
that she would die before evolution could take place spontaneously. 

I opened the thorax at the axilla, and broke up the tissues within 
both pleural cavities. Then, by means of the crotchet, I drew down 
rib after rib, — the flank, the hip, and the buttock, so that I got the 
left thigh and leg down; then the other extremity, which completed 
the evolution. The arms came down and I delivered the head. The 
woman recovered happily. 

I relate the case in order that the Student, reading it, may have a 



PRETERNATURAL LABOR. 377 

clearer idea of what is meant by evolution in contra-distinction to 
turning of the child. 

Hemorrhagic Labor. — Labors are also rendered preternatural by 
the occurrence of hemorrhage from the womb; for, although it is very 
common, and not unfavorable for the parturient woman to have an 
issue of blood during some part of the process of child-birth, it is not 
either safe or natural for her to lose so much blood as to give to the 
flow the character or title of hemorrhage. In general, the quantity 
lost antecedently to the birth of the child does not exceed an ounce, 
and it is commonly even less than that. The occurrence, therefore, 
of a show of blood need not, and does not excite any alarm or even 
surprise, unless it goes beyond the ordinary amount. But where the 
effusion becomes excessive, great alarm is felt, and there is more or 
less real danger according to the cause of the accident. 

I have already expressed my opinion of the mode of connection be- 
tween the placenta and the womb ; and the Student will have seen 
that I do not admit that any very krge vessels pass from each to the 
other, interchangeably. Hence, when blood escapes from the uterus, 
it must be, I think, in consequence of a hemorrhagic nisus or san- 
guine determination, like that which sometimes causes the effusion 
of blood from the Schneiderian membrane, in those cases of epistaxis 
that come on spontaneously. We often see very copious outpourings 
of blood in epistaxis, where we can have no reason to suspect any 
rupture of vessels or solution of continuity in the membrane. The 
same thing takes place in the pulmonary hemorrhage, and in haema- 
temesis. But as the womb, from its very constitution, is prone to 
the hemorrhagic affection, it is more liable than any of the organs to 
losses of blood, without the suspicion of rupture of its tissues. Never- 
theless, there is reason for believing that in some cases of profuse 
bleeding the delicate tissue of the uterine veins has been ruptured. 

The gravid womb is filled with the ovum, which is really connected 
with the containing organ only at the placental superficies. All other 
points of the ovum, except the placental portion thereof, adhere so 
slightly as to be most easily capable of detachment. The placenta 
itself may commonly be separated with great facility from the surface 
on which it sits. When the chorion is detached from the womb, very 
little or even no blood escapes; but when the placenta is torn off, the 
womb generally, not always, bleeds very freely. Hence, large effu- 
sions of blood, in labor, indicate that the placental surface of the 
womb is exposed by the separation of the after- birth from it. 



378 PRETERNATURAL LABOR. 

If the after-birth is torn off, or in any manner separated from its 
place, the womb still remaining undiminished in size, it is evident 
that the blood may continue to flow for an indefinite period, and that 
the woman may be brought into great danger thereby — for the bleeding 
orifices may continue to have, for an indefinite term, the same degree 
of aperture as that which first caused them to bleed. Supposing 
the superficial content of the gravid uterus to be two hundred square 
inches, and that of the non-gravid womb to be only three square 
inches, then it is evident that the great desideratum in uterine hemor- 
rhages, before delivery, is to empty the organ as soon as practicable, 
in order to reduce its superficial content, as nearly as may be, to the 
smallest number of square inches, or the non-gravid state. In treating 
the cases of alarming hemorrhage, therefore, we should ever keep in 
view the fact, that if the womb be allowed to contract or condense 
itself, its own muscular fibres will, by their contraction, lessen the 
calibre of all the blood-vessels that are distributed on or in the organ, 
and in proportion to this condensation or contraction will be the cer- 
tainty of arresting the sanguine effusion. It is not only the orifice 
that is closed, but the whole tractus of the vessel is constringed. 

If a labor should commence ever so favorably, with the child pre- 
senting the vertex in the first position, and the pains should propel 
the child downwards, so as to give reason to think the process about 
to terminate in the most happy manner, yet it might happen that 
hemorrhage should commence, and continue so abundantly, as to 
make it absolutely necessary to deliver the child, in order to let the 
womb contract perfectly. This delivery by artificial means converts 
the labor, which commenced naturally, into a preternatural one. 
We should hardly be inclined to call that a preternatural labor 
which, though accompanied with a great effusion of blood, should 
terminate well, without any assistance on the part of the accoucheur. 

There may also be a very copious and dangerous effusion of blood 
between the birth of the child, and the delivery of the after-birth; and 
even when the after-birth has been discharged, the flow of blood may 
be so considerable as to involve the woman in the greatest danger. 
In the management of all these kinds of bleeding, the same indica- 
tion is to be kept always in view; to wit, the condensation or con- 
traction of the womb ; for when that organ is fully contracted and 
condensed, the blood does not flow so abundantly as to endanger the 
patient, except in some very rare, and almost unheard of cases. 

But among the causes of uterine hemorrhage, there is one which 
has been called the unavoidable cause, which is, perhaps, the most 



PRETERNATURAL LABOR. 379 

dangerous and difficult to manage: I mean that case which depends 
on the situation of the placenta happening to be on the cervix and 
os uteri. This is essentially a hemorrhagic labor, inasmuch as the 
mouth of the womb must not only dilate, but must dilate completely, 
in order to admit of our carrying out the great principle, the final 
condensation of the womb. Such a hemorrhage begins very mode- 
rately, but as larger and larger portions of the placenta continue to 
be detached with every successive dilating pain, it follows that the 
nearer the womb is to its complete dilatation, the more profuse and 
dangerous will be the hemorrhage. 

Every considerable effusion of blood in labor does not demand the 
manual or instrumental assistance of the accoucheur. A woman 
may shed a quart of blood, and yet the pains may suffice to expel 
the fetus in a natural way, after which the flow ceases. It is the 
effect, or the probable effect, of the bleeding, that renders it needful 
to interfere. If the pulse begins to grow small and frequent, the 
patient becoming w T eaker, the countenance paler, and the pains less 
energetic, we have to resolve what course we must take, and then 
resort to some of the numerous expedients for checking the discharge. 

If the pulse in uterine hemorrhage be full and throbbing, and the 
constitution not affected with debility, we may, with great safety and 
propriety, have recourse to a bleeding from the arm, in order to lessen 
the momentum of the blood, which, by its too great impetuosity, tends 
to keep up the flow and the determination to the womb — just as we 
would bleed in a pleurisy or hsemoptoe, with a similar view. Such 
a course, however, would be very strongly contra-indicated in the 
case of a feeble pulse, and a general state of weakness, faintness or 
sinking, w T here there would be no reasonable ground to hope for relief 
by the use of venesection. 

The application of cold to the hypogastric region, is often found to 
have a good effect in checking the sanguine effusion, and should be 
freely resorted to by stuping the lower belly with napkins, hard wrung 
out of cold vinegar and water; the application being renewed from 
time to time, until we are satisfied that success is, or is not, to crown 
our efforts. During the employment of the above mentioned means, 
the patient ought to be placed in a horizontal posture, with the head 
very low, and the body covered only with sufficient bed-clothes to keep 
her comfortable, — the apartment should be freely ventilated, and the 
patient allowed to take any reasonable quantity of iced water, or 
lemonade, w 7 hile she at the same time makes use of the infusum rosae 
rubrse with elixir of vitriol, or the plumbi acetas with opium. 



380 PRETERNATURAL LABOR. 

Such are the general means for repressing the sanguine movement 
towards the womb ; but these means do not suffice always, and we 
ought to examine by the Touch, in order to make sure, if possible, of 
the cause of the hemorrhage. If, upon inserting the finger within 
the os uteri, no portion of the placenta can be felt, and the membranes 
are found to be unbroken, we may perhaps resolve to rupture the 
ovum, with a view to diminish the size of the womb by letting its 
waters run off. If a quart of w T ater should escape from the organ 
immediately after the breaking of the membranes, the superficies of 
the womb, and of course the placental superficies would be sensibly 
lessened, since the organ contracts as soon as the escape of the waters 
permits it to do so. This is the method proposed by Louise Bour- 
geois, a female practitioner in France, many years ago, and it is found 
to answer perfectly well, in many cases. 

There are circumstances, however, that might well induce one to 
defer to the latest period the breaking of the ovum; such as a known 
bad presentation of the child, requiring it to be turned. In such a 
case, no prudent person would be willing, without an absolute neces- 
sity, to permit the water to escape from the womb previous to dilata- 
tion, since the operation of turning is vastly more difficult, when per- 
formed in a female from whom the waters have been quite evacuated, 
than in one in whom they are still present. Hence, if the mouth of 
the womb be still very rigid and undilatable, rendering it impossible 
or improper to introduce the hand for turning, any prudent person 
would give a very deep consideration to the question, whether the 
membranes ought to be broken or not ; and would certainly feel in- 
clined to defer, till it should become unavoidable, the rupture of the 
membranes. 

If, upon rupturing the ovum, the flow of blood should not be stayed, 
and the os uteri should still continue to be so rigidly contracted as to 
make it impossible to turn the child, recourse should be had to the 
ergot, in very small doses, with a view of producing a feeble ergotism, 
or tonic contraction of the womb, not severe enough to injure the 
child, but yet, so strong as to condense the uterine tissue sufficiently 
to arrest the flow of blood from its vessels. With this purpose, five 
grains of the secale cornutum, in powder, ought to be administered 
every half hour or every hour, according to the pressing nature of the 
demand for its aid; or a teaspoonful of the vinous tincture of the 
same article might be exhibited, at proper intervals, with the same 
view. 

There is, in general, under these circumstances, a strong disposi- 



PRETERNATURAL LABOR. 381 

tion to make use of mechanical means of stopping the hemorrhage, 
such as the application of napkins to the vulva, strongly compressing 
the orifice; and also the plug or tampon, which, filling the vagina, is 
supposed to favor the coagulation of the blood. But, if it be remem- 
bered that the bleeding orifices of the placental superficies on the 
womb, are near the fundus uteri, and that the extravasated fluid 
trickles down, betwixt the chorion and the womb, from the fundus to 
the orifice, I think it will be seen that such mechanical means can 
scarcely exert any other than injurious effects in the case. They 
may enable us to conceal the fact both from the patient and from 
ourselves, that the vital fluid is escaping in a dangerous abundance; 
but common sense ought to show us, that while we may prevent the 
fluid from falling out of the orifice of the vagina, by plugging that 
orifice with sponge or other materials, we do not prevent it from flowing 
back upon the outer surface of the ovum and the placenta, both 
of which it detaches more and more completely from the womb, 
leaving the woman exposed to greater hazard than she would incur 
were we to permit the blood to escape as fast as it is effused. Such 
methods, assuredly, will not favor the arrest of the effusion by coag- 
ulation ; the source of the flow being too distant from the remedy. 
It is, in general, better, in uterine hemorrhage, to let all the blood 
that escapes from the vessels, also escape from the vagina. When 
the uterine superficies is diminished, the bleeding is stayed. The 
application of cloths, wrung out of iced vinegar and water, to the 
hypogastrium, is of greater avail, and far more safe than the tampon. 
I would gladly urge upon the Student the necessity of the greatest 
caution in the employment of so dangerous an agent as the tampon, 
except in the early stages of gestation, or where the capacity of the 
womb is not sufficiently great to admit of its containing a great quan- 
tity of blood. No hemorrhage is so dangerous as the concealed he- 
morrhage. 

Whenever it is clearly ascertained that the period has arrived for 
the delivery to be hastened, which is known by the state of the 
patient's strength, the pulse, the color of her lips and cheeks, and 
by the dilatation or dilatability of the mouth of the womb, preparation 
should be made for the operation by placing the woman at the foot 
of the bed, as in the case before mentioned. The choice of means, 
whether it is to be of the hand or the forceps, will turn on the degree 
of advancement of the head, which is readily seized by the forceps, 
if low in the pelvis, but which is to be pushed away to make room 
for the search after the feet, provided it be still within or above the 



382 PRETERNATURAL LABOR. 

brim of the pelvis. In all cases wherein the vertex is to the left side 
of the antero-posterior diameter of the pelvis, the left hand is to be 
used; while the right hand is adapted for turning, in all examples of 
labor where the vertex is to the right half of the pelvis. The operation 
differs, in no respect, from the one already described, except that the 
head must be pushed out of the way, instead of the shoulder. If the 
head should have already occupied the upper strait, that strait would 
be nearly filled with the mass ; the hand could not be carried up 
along-side of it. The palm of the hand, therefore, being placed under- 
neath the head, would push it gently upwards, in the absence of pain, 
and carrying it to one side, it would be retained on the brim, by the 
wrist or arm of the physician, which occupies the space recently in 
possession of the head. The exploration or search for the feet would 
be conducted as in the case already treated. 

When I come to speak of the use of the forceps, I shall say what 
is requisite concerning the indications and manner of its use in the 
hemorrhagic affections ; wherefore, it seems by no means needful for 
me to anticipate here, what I shall feel obliged to say in a future page 
of this book. 

Placenta Previa. — The unfortunate location of the placenta on 
the cervix and the os uteri is an accident which does not very fre- 
quently happen, and which, when it does occur, can scarcely ever 
fail to produce much anxiety and alarm among all those who under- 
stand the case, and feel any interest whatever in the mother and 
her offspring. The after-birth may cover the os uteri so exactly, that 
the very centre of the placenta may correspond to the orifice. The 
danger is enhanced by as much as the location is more central, that 
case being the least dangerous in which the edge of the placenta is 
nearest to the os uteri. 

The occurrence will not probably be discovered until about the 
seventh month, a term at which the cervical portion of the womb 
begins to expand, in order to become a part of the general containing 
cavity for the ovum; and it is in some instances not discovered, or 
even suspected to exist, until the labor at full term comes on. In a 
majority of cases, however, it happens that as soon as (in the seventh 
month) the cervix begins to stretch, parts of the placenta are broken 
off or detached from the surface of the womb, and a flow of blood, 
more or less violent, ensues, but which stops as soon as the patient 
lies down, or makes use of a venesection or some cooling drinks. The 
flow having been concluded, it is thought to have depended upon some 



PRETERNATURAL LABOR. 383 

strain or shock, &c. &c, and the patient, having recovered, goes 
about her usual occupations. In a short time, a further expansion of 
the cervix detaches a fresh portion, and the exposed womb bleeds 
again. These attacks of bleeding are renewed again and again, 
until, by their violence or the weakness they produce, such an alarm 
is taken, that an examination per vaginam is proposed, and acceded 
to, when the cause of so much bleeding is discovered in the fact of 
the untoward location of the after-birth. It does not invariably happen 
that the woman bleeds previously to the attack of labor pains, but it 
is far too general an occurrence not to cause the danger of such fre- 
quent repetitions to be kept before our eyes, until the patient is finally 
delivered. The loss of blood by repeated attacks, during the last 
two months or six weeks of gestation, renders the subject of them far 
less capable of bearing the frightful effusion with which she is me- 
naced for the day of her parturition ; and a woman who should go 
into labor with a good stock of strength, could bear, without injury, 
a very copious draught on the sanguine mass, whilst another one, 
with vessels already drained, should sink, from the further exhaustion 
of a few ounces. I saw, about two years ago, a woman drained 
nearly to the last drop that could be spared in a labor that had been 
preceded by many attacks of bleeding from a placenta prsevia. 

Hemorrhage arising from the presence of the placenta at the os 
uteri, called placenta prsevia, is also denominated the unavoidable 
hemorrhage. The case should be always suspected to exist when 
pregnant women are attacked with hemorrhage between the seventh 
month and Term; and the existence of it should be verified or dis- 
proved by an examination. If it be found to exist, then the friends 
of the patient, but not the patient herself, ought to be notified of the 
nature of her position ; full instructions ought to be given for the 
management of any future attacks in the physician's absence ; and 
the services of another medical practitioner should be retained for 
all sudden emergencies, during the absence of the regular attendant. 
By such attentions as these, the patient might confidently expect to 
secure the services of at least one medical man, should her own 
regular physician happen to be engaged when her time of suffering 
arrived. 

When the placenta is previa, it will be almost certain to produce 
a bleeding before labor comes on. But that bleeding will be far 
more likely to occur in a woman who exposes herself to fatigue and 
various causes of excitement, or to accidents, than in a woman who 
keeps herself quiet, carefully avoiding to make any great exertion, or 



384 PRETERNATURAL LABOR. 

to experience severe emotions of the mind. In all cases of a strong 
predisposition to bleeding, an increased momentum of the blood aug- 
ments the predisposition. Hence, cooling diet, gentle aperients, small 
venesections, and repose, and relaxation from labor especially, ought 
to be very carefully prescribed for our patient. The friends should 
be enjoined to give us the earliest notice of the attack of labor pains, 
or flooding, so that, all preparations being complete, we may have 
nothing to embarrass us in the exercise of our judgment, during the 
actual progress of the labor. 

The hazard of perishing to which the patient is exposed, depends 
on the dilatability of the os uteri, and the strength of the pains to be 
employed in dilating it. If it be soft, and the pains strong and good, 
the dilatation may be completed so rapidly as to prevent the effusion 
of any very great quantity of blood. If, on the contrary, it be rigid, 
and yield very slowly to the feeble contractions of the fundus, the loss 
of blood may be very great, and the woman sink before the mouth of 
the womb becomes prepared for the introduction of the hand. It 
must be prepared before the hand is introduced. There is no more 
important doctrine, in operative midwifery, than that which avers 
that we must never presume to force the uterus until dilatation or 
dilatability abstracts from the operation of turning one of its most 
objectionable characters. Dr. Collins, in his late work, speaks so 
sensibly upon this subject, that I shall not refrain from quoting the 
following passage from page 93 of his book. 

"I know of no circumstance so much to be dreaded, as the forcible 
introduction of the hand where the parts are in a rigid or unyielding 
state; for* although turning the child is the established and most de- 
sirable practice, yet the success of this operation will mainly depend 
on the judgment of the practitioner in selecting the most proper and 
favorable time. Cases will happen where he is obliged either to 
suffer his patient to sink from loss of blood, or proceed to deliver when 
the parts are in an undilated and rigid state, in order to afford her 
the only chance of life; but dire necessity should alone compel him 
to hazard the consequences of such violence." 

Such is the language of an eminent author, who has witnessed a 
vast number of labors, and whose ample experience gives him a 
title to speak as of authority upon this and all other subjects con- 
nected with midwifery. 

The time for delivery having arrived, the woman, if sufficiently 
strong to bear it, should be brought to the edge of the bed, and placed 
on her back; otherwise, she should not be moved, but attended to as 



PRETERNATURAL LABOR. 385 

she lies. If the head present, and the position be unknown, we ought 
to infer that the vertex is to the left acetabulum, which is the most 
common one, and of course commence the operation with the left 
hand. The palm of the left hand easily applies itself to the face, 
breast and abdomen of the child lying in the first vertex position — 
and of course that is the hand most conveniently applicable to the 
operation of turning. 

In some instances, as when the patient is not very fat, we may 
detect the position by external exploration, for we may trace the 
curve of the spine of the child from the buttock to the head with our 
hands applied to the belly of the parturient patient during the absence 
of the pains. — It is very desirable, in this operation, to use the hand 
first, with which the whole operation is to be effected — and not intro- 
duce it and take it away in order to introduce the proper one. — Time 
and blood, are both liable to irreparable loss by such manoeuvres. 
By means of the fingers, we soon learn which side of the uterus is 
detached from the placenta, and then conduct the fingers in that 
direction, dilating the womb as we proceed, and carrying the fingers 
as far upwards as we conveniently can, betwixt the womb and the 
chorion. Tr^ membranes may then be ruptured high 'up in the 
uterus, and the feet immediately sought for; the child should be turned 
as speedily as possible, with proper regard to its safety and that of 
the mother; and the legs, and even the thighs, should be drawn into 
the vagina, not only with the view of expediting the delivery, so as 
to permit the womb to contract, but also in 'order that the thighs or 
body of the child being come into the cervix, may, by compressing 
the bleeding parts there, arrest or impede the flow, and thus save for 
the patient as many ounces of blood as possible. It is to be remem- 
bered that it is the loss of the last half pint of blood that kills the 
patient. I think that no prudent person would undertake to pierce the 
placenta, in order to get the hand within the womb. There never can 
be so much difficulty in detaching, as there would be in piercing the 
organ; and these two objections lie against perforating it, namely, 
that the rupture or laceration of its vessels could not but be destruc- 
tive to the child, which would bleed to death ; and also, that if the feet 
should be dragged through a perforation made in the placenta, the 
final delivery of the body and head might be very much retarded, by 
having that mass to pass through, in addition to the other obstacles 
to the birth; and further, it is evident that in perforating the placenta 
and extracting the child through its centre, the organ could scarcely 
fail to be very completely detached from the womb, while only a par- 
25 



386 PRETERNATURAL LABOR. 

tial detachment is required if it be made on one side. It is best, 
therefore, in all cases, to pass the hand betwixt the placenta and the 
womb, and not through the placenta. 

A strong desire to reinforce the tonic contractility of the womb 
w r ould induce me, always, to exhibit a portion of the secale cornutum, 
in these cases, taking care to time the dose so as to secure its ope- 
ration for a period subsequent to the delivery of the child. The ergot 
should be in readiness, and given as soon as the turning is completed. 
If it should operate successfully upon the uterine muscular fibres, it 
could not but afford additional hope of preserving the patient, at least, 
from the danger of a good deal of drainage, if not from a more violent 
and rapid effusion subsequently to the delivery. So confident am I 
in the power of the ergot administered in this way, that I venture to 
recommend it very strongly. Many persons, who were constitutionally 
prone to hemorrhage after delivery, have escaped well, from having 
taken the spurred rye, in the last moments of labor, in order to secure 
a tonic action of the uterus after delivery of the child. 

I need not reiterate my opinion that the operator should not be unpro- 
vided with the forceps, with which to extract the head, in case of any 
uncommon or dangerous delay in its delivery, as I have already stated 
my opinion that such means of security ought to be provided for every 
instance of breech labor, or preternatural presentation, of whatever 
species. 

Fortunately, for us, we do not have to contend with a great many 
cases of placenta prsevia. I have seen six cases of these accidents, 
in which the orifice was completely covered by the after-birth, and 
several others in which the edge of the placenta was located on the 
cervical portion of the womb, and occasioned a certain degree of 
hemorrhage, during the dilatation, but not to any dangerous or alarm- 
ing extent. 

Dr. Collins mentions, that eleven cases occurred during his master- 
ship of the lying-in hospital, equal to one case in one thousand three 
hundred and ten labors, since he had sixteen thousand four hun- 
dred and fourteen labors during his mastership. 

It is rather a surprising circumstance that Mauriceau, who was so 
largely engaged in midwifery practice, and who witnessed a good 
many cases of placenta praavia, should have been supposed to be 
ignorant that the original attachment of the after-birth was on the 
cervix. It has been asserted that this distinguished writer always 
supposed, that when the placenta was before the child, it was owing 
to an accidental detachment of it from the fundus, in which it had 



PRETERNATURAL LABOR. 387 

fallen down to the orifice, so as to get in advance of the presenting 
part ; and yet, he very distinctly gives directions how to pass the 
hand, so as in the easiest way to get it by the placenta, when the 
operation of turning has to be performed; and the twenty-eighth 
chapter of his second book is devoted to a very full account of the 
mode of delivery in such cases — and he gives at full length the de- 
scription of twelve cases of placenta prsevia most admirably managed 
by himself, which are in the first volume. The celebrated Levret 
gives us, in his article on placental presentations, an elaborate resume 
of the history of opinions on that accident which had been expressed 
by writers antecedent to him. It seems that many practitioners had 
treated the case, and well too, but without possessing such correct 
notions upon it as are entertained at the present time. 

It will have been perceived that I have not, in this article on pla- 
centa prsevia, adverted to the new method of treatment which has 
been so strongly advocated by Drs. Simpson, Radford and other emi- 
nent persons among the brethren, in England and in this country. 
I mean the total separation of the placenta, by the hand of the accouch- 
eur as a certain method of putting a stop to the effusion of the blood. 
The journals and other publications, in which this treatment has been 
set forth and recommended, contain the relations of numerous cases 
in which the placenta was either accidentally or designedly separated 
from its place on the womb, and in which the blood ceased to flow 
immediately after the complete detachment of the after-birth. The 
good success of this practice has begun to render it very popular, and 
I think that too much confidence is reposed in its power to arrest this 
most dangerous flooding. It has been supposed heretofore that alarm- 
ing uterine hemorrhages proceed from patulous orifices of vessels 
of the womb, and that the essential remedy for these effusions consists 
in the condensation of the uterine texture under the active contrac- 
tility of its muscular fibres. But the advocates of the new practice 
in placenta prsevia explain their success and urge the adoption of 
their method upon the new ground that the blood flows, not from the 
uncovered portion of the uterine placental superficies, but from the 
uncovered surface of the placenta itself, averring that while a part of 
the placenta is detached and the rest of it retains its adherence to the 
uterine surface, the blood of the uterus continues to pass into the cells 
of the placenta from whence it escapes into the cells of the detached 
portion, issuing in torrents from its free surface, and the idea is en- 
tertained that by w 7 holly separating the placenta from the womb, no 



388 PRETERNATURAL LABOR. 

more blood can gain admission to the cells of that tissue, and there- 
fore no more blood will be lost. 

Entertaining these views, which I have already at page 172 expressed 
as to the constitution of the placenta, and its connexion with the 
uterus, it is clearly impossible for me to admit the truth of the foregoing 
explanation of the hemorrhage in placenta prsevia. 

To say that the detachment of the placenta, without any consequent 
reduction of the superficial contents of the uterus, could arrest a hem- 
orrhage by breaking of! the curling arteries (as they are called), of 
the womb, appears to me quite unphilosophical — for there are thou- 
sands of facts of ante-partum and post-partum hemorrhages to prove 
that the arrest of hemorrhage is the consequence of condensations 
of the womb under its muscular contraction. 

The incision of the womb in a Cesarian operation, often cuts 
through the most vascular part of the organ, and as the bistoury sinks 
into the tissue, the blood spurts from numerous divided vessels; but 
as soon as the child and the secundines are taken out of its cavity and 
the organ allowed to contract, the immense orifices are nullified by the 
condensation of the texture: — a cut of five inches in length being 
immediately reduced to a length of not more than two or two and a 
half inches, and its incised edges scarcely allowing of the smallest 
sanguine exudation. 

This I have observed to happen in the case of Mrs.Raybold, whose 
case is related in this work. To separate the placenta, and not allow 
the womb to contract, is to gain nothing, for the hemorrhagic moli- 
men, or the mere traumatic flow, cannot be supposed to cease merely 
because the curling arteries (so called) are broken ofF. 

Further, in placenta prsevia the effusion is in many instances most 
dreadful long before the hand of the accoucheur can be passed up- 
wards, in order to turn and deliver. Nay, it is alarmingly great in 
some samples, while the os uteri is still not larger than a quarter 
dollar. But as the placenta is eight inches in diameter, it seems to 
me not possible to detach the whole viscus with a finger, which is not 
long enough to reach the very circumference of a centrically im- 
planted after-birth, and, a fortiori, not long enough to reach to the 
remote edge of one not centrically implanted. 

If the os uteri be dilated, or dilatable enough to introduce the hand 
for turning, the time has arrived for this operation, and there is then 
assuredly no occasion to detach the placenta. Let the operation be 
performed at the earliest possible period, for the indication, as in 
all dangerous uterine hemorrhages, is to let the womb contract, which 



PRETERNATURAL LABOR. 389 

it cannot effectually do until the ovum is extracted or expelled from its 
cavity. When that is done, it speedily draws itself to the smallest pos- 
sible cubic content. Messrs. Simpson, Radford, and the other gentle- 
men who advocate the new method in placenta prsevia, very earnestly 
recommend the prompt separation of the whole of the placenta; and 
they are persons whose opinions are justly to be esteemed of the greatest 
w~ eight ; but notwithstanding the profound respect with which I receive 
any statement of theirs, I cannot but think that in any case in which it is 
possible to detach the whole of the placenta, it would be also possible 
to introduce the whole of the hand, and thus commence at once the 
operation of turning, which ought to be esteemed as the essential 
indication of treatment in placenta prsevia, and which the earlier it is 
done, so much the greater chance does it give both of rescuing the 
child and saving the woman from fatal losses of blood. 

Heretofore in turning for a shoulder presentation, I have found the 
placenta lying at the fundus uteri wholly detached and without any 
immediate hemorrhage; but I have seen a vast number of most 
dangerous post-partum hemorrhages occasioned by coagula filling the 
vagina and acting there as a tampon, allowing the uterus to expand 
again with influent blood and rendering the orifices of vessels upon 
its placental superficies nearly as patulous as before the birth of the 
child. I cannot suppose, therefore, that w r hen I have found the pla- 
centa wholly detached at the fundus uteri in a labor, hemorrhage failed 
to occur because of that detachment; nor can I suppose that in pla- 
centa prsevia, hemorrhage is arrested because of the artificial detach- 
ment ; but rather in both cases from association of the hemorrhagic 
molimen. 

Concealed Hemorrhage. — There is another kind of hemorrhage 
that is met with in parturient women ; I mean the concealed hemor- 
rhage. It may take place from the placental surface, and continue 
to a dangerous extent, without detaching the circumference of the 
after-birth from its connection with the womb. In this case, the whole 
placenta is separated from the womb, with exception of its rim; and 
the distensible material admits of so large a quantity of blood being 
effused, as to make it take the appearance of a bag filled with blood, 
and depressed into the uterine cavity. I have never met with a 
sample of this kind of bleeding; but the phenomena that accompany 
excessive loss of blood would give intimation to an intelligent phy- 
sician, in such a case, sufficiently clear to engage him to proceed 
aright in lessening the bleeding superficies, either by merely dis- 



390 PRETERNATURAL LABOR. 

charging the liquor aranii, or by turning, or delivering with the 
forceps. The symptoms, under such circumstances, would be weak- 
ness; dull pain in the womb; suddenly increased size and tension of 
the organ; frequency and smallness of the pulse; paleness ; yawning 
and sighing; and syncope. The occurrence of such phenomena, in 
a pregnant woman, if alarmingly great, would, I think, be a full war- 
rant for opening the ovum, or for an expeditious delivery; the latter, 
always, however, to be held in reserve until the womb is dilated or 
dilatable. Such a case, however, deserves to be profoundly consi- 
dered before proceeding to the adoption of an extreme measure. 
The ergotic action might be, with great prospect of advantage, re- 
sorted to, in case the hemorrhagic symptoms should not abate upon 
the discharge of the liquor of the amnios. 

Post-Partum Hemorrhage. — The hemorrhages that take place 
between the delivery of the child, and the expulsion of the placenta, 
are frequently to be met with, and are so violent, as to excite great 
alarm in the patient herself, or her friends who happen to witness the 
distressing symptoms that accompany the accident. I think, that, in 
a very great majority of labors, the placenta is quite detached by the 
time the child's head has emerged from the vagina, and that the 
separation frequently takes place still earlier. 

In such women as have feeble pains, with long intervals, the effu- 
sion of blood is sometimes very great, and a large quantity frequently 
is found to be expelled immediately after the child is born, being evi- 
dently the result of hemorrhage taking place in the intervals between 
the pains, yet detained behind or above the presenting part, until the 
delivery of the child is completed, when it rushes forth with great 
violence. If this is a correct statement, then it may, a fortiori, happen, 
that the effusion may go on rapidly as soon as the body of the child 
has escaped. The womb, in many instances, is perfectly passive for 
some time after the great effort it has made, and the placental super- 
ficies being exposed, a torrent of blood issues, which suddenly fills 
and distends the womb, and the woman faints and dies without any 
one perceiving that she has flooded at all. I believe that the blood 
would always flow out of the vagina, were it not that a firm clot occa- 
sionally happens to stop the os uteri, like a tampon, so that none can 
escape ; and if the womb be deprived of its irritability, its fibres will 
offer no resistance to the fluid which is poured into the cavity, and 
which, being sealed up by a coagulum at the os uteri and in the 



PRETERNATURAL LABOR. 391 

vagina, must distend more and more, and with a rapidity that aug- 
ments as the placental surface grows larger and larger. 

A careful practitioner ought not to allow such an event to take 
place, in his presence. He will frequently place his hand upon the 
hypogastrium of his patient, and ascertain whether the womb be pro- 
perly contracted, and enforce its contraction, if necessary, by frictions, 
and by gently pressing the womb with his fingers applied to the lower 
part of the abdomen. The irritability of the organ is readily excited 
into effect by this means; and when the womb becomes properly con- 
densed, there is little danger of any effusion taking place. It should 
be an invariable custom to place, after the child is 
born, the hand on the mother's abdomen, to make sure 
of the contraction of the uterus. This custom will always 
give prompt information of the existence, or non-existence, of a tonic 
contraction ; and he who fails of attention to this point will, sooner 
or later, have reason to regret the neglect of so salutary a precaution. 

But when flooding comes on, whether after delivery or antecedently 
to it, the same principle is applicable, namely, to empty the cavity as 
speedily as possible consistently with prudence. Let the placenta be 
taken away, and, after its removal, let pressure be made on the hypo- 
gastrium by the hand, or by a compress and bandage, and the pres- 
sure continued until the signs of hemorrhage have completely ceased. 
After having removed the placenta, or after having turned out from 
the cavity of the womb a pound of coagula, more or less, the woman 
cannot be deemed safe until the lapse of an hour or more shall have 
given assurance that no repetition of the hemorrhage can take place. 
I have, on a great many different occasions, found myself compelled 
to turn out the clot again and again, to prevent the patient from falling 
into fatal syncope. Let the Student therefore take heed, that while 
he may have saved his patient from fatal hemorrhage at ten o'clock, 
she fall not into the same hazard again at half-past ten or eleven, or 
at half-past eleven, being careful not to quit her apartment till he can 
clearly pronounce her safe. 

It happens that the womb is incapable, sometimes, of separating the 
placenta wholly from its surface; but if it be half detached, there may 
flow a great quantity of blood, while the uterus continues unable to 
expel the after-birth. The duty of the medical attendant here is to 
separate it entirely, by introducing his hand, and gently detaching it 
with his fingers, taking every possible care not to leave any portion 
behind, which, by keeping up a continued irritation, would tend to 
maintain a hemorrhagic nisus, or even dispose the patient to metritis. 



392 



PRETERNATURAL LABOR. 



He will separate the placenta here, in order to let the uterus contract, 
for the suppression of the hemorrhage, which it will do as soon as it 
can thrust the placenta forth from its cavity. Let it be always re- 
membered that the hand is not to be introduced unless real need for 
it exists. 

The greatest care should be taken in this case to keep the patient 
quiet, and strict order should be given not to lift her head from the 
pillows, until all the appearances of danger are gone. Any attempt 
to sit up in bed, or even to turn, for a woman excessively reduced by 
hemorrhage, is dangerous, since any muscular effort, by occasioning 
faintness or exhaustion, invites a renewal of the hemorrhage and de- 
bility, which are both to be deprecated. 

Hour-Glass Contraction. — I have met with several examples of 
the hour-glass contraction of the womb, of which I have spoken at p. 
299. This depends upon the contraction of the womb at the upper 
limit of its cervical portion, so that the after-birth is contained, as it 
were, in a separate cell, or the contraction may take place so as 
merely to include the placenta, still retaining its original connection 
with the uterus. The finger may pass up to the constricted point, 
and find the cord closely embraced by it. If no bleeding comes on, 
it is proper to wait an hour, to see w T hether the co-ordinate action of 
the muscular fibres will not overcome the horizontal constriction; 
but, if an hour elapses without the least change in the case, we have 
reason to infer that two, or even four hours, may not suffice to remove 
the difficulty, and we are always justified in taking away the secun- 
dines in that time, even should we not be prompted to do so earlier. 
It is, in general, not difficult to overcome the stricture, by introducing, 
first, the hand into the vagina, and then inserting one, then more 
fingers along-side of the cord, until a sufficient portion of the hand 
is introduced to command the placenta. 

I have never yet met with an hour-glass contraction in which I 
was not compelled to separate the placenta with my hand. 

I can not well conceive of an hour-glass contraction, independently 
of a preternatural adherence of the after-birth to the womb. 

I suppose that when the after-birth is so firmly attached that the con- 
tractions of the womb cannot slide it off, the substance of the placenta 
acts as a soft splint — counter-extending the utero-placental superficies. 
The rest of the womb, having nothing to antagonize it, contracts as 
usual, leaving the placenta shut up in an upper cell. It usually con- 
tracts at the upper extremity of the cervix ; sometimes, as where the 
placenta is situated upon the side of the womb, and cannot be dis- 



PRETERNATURAL LABOR. 393 

placed by its contractions in consequence of the preternatural adher- 
ence, the cell in which it is contained is on the side of the womb, 
and the fingers, in dilating the constricted part, must be conducted 
to the right, or to the left, or to the front, or backwards into the 
chamber containing the after-birth, as the case may be. 

If this explanation be just, there is no very well founded reason to 
hope for the spontaneous expulsion of the cake — for the adhesion will 
not give way after the birth of the child, if it would not before that 
event. Thus the indication in hour-glass womb is, perhaps, to deliver 
at once, and I now heartily and warmly advise the Student to intro- 
duce his hand to separate the placenta, as soon as he can clearly 
determine that the real hour-glass contraction does exist. He will 
be compelled to do so, sooner or later — and the sooner it is attempted, 
the easier will it be effected. 

What can be more disagreeable, or even distressing, than be com- 
pelled to carry the hand and half of the forearm into the body of a 
patient already weakened and exhausted by the labor, and above all, 
to be obliged to remove from the womb w T hile the female is agonized, 
the adhering mass, which sometimes is so closely united as to be 
apparently confounded with the texture of the womb. I am sure that 
in performing this painful office, one is occasionally obliged by a sense 
of duty to the patient to continue the effort to get off the placenta, even 
w T hen far from certain that one is not either leaving portions of the 
lobules still united, or perhaps injuring the vital tissue itself; all that 
can be expected of any practitioner, under such circumstances, is that 
he should faithfully do his duty according to his ability. If he cannot 
get off the whole after-birth, he must leave portions of its lobules. Let 
him, however, always try to get every vestige of it off. To leave an 
ounce adhering is better than to leave a pound, and he can and ought 
to protect his own credit against any untoward results, by a full and 
candid statement of the difficulty he has met with, and of the imprac- 
ticable nature of the case. I have taken away a great many such, 
and none of the women have failed to recover, even where I was cer- 
tain that my utmost care and desire to succeed in removing the whole 
had been in vain. The Student will learn in practice that he will 
rarely meet with these vexatious adhesions, in cases that go on regu- 
larly and with a proper celerity, but if he have a labor that gives him 
great trouble and long detention, from irregular action and feebleness 
of the pains, he may justly fear that the after-birth will not come off 
easily. I doubt not that a very firm adhesion of the after-birth is capa- 
ble of greatly impairing the regularity and strength of the uterine con- 
tractions. Such an after-birth, by preventing that part of the womb 



394 PRETERNATURAL LABOR. 

in which it is from contracting in due proportion with the other parts of 
the organ, is very probably the cause of most of the difficulty we have 
to contend with throughout the whole parturient process in such a 
case. 

Hemorrhage following the After-birth. — The application of a 
compress, made by folding one or two napkins, and securing them 
upon the lower part of the abdomen by the common bandage, is a 
precaution that ought never to be overlooked where there is a great 
disposition to hemorrhage. Such a pressure not only prevents the 
womb from filling again, but it tends very successfully to secure a 
firm tonic contraction of the organ. 

The sacchar. saturni, combined with opium, in doses of three or 
five grains of the former with from half a grain to a grain of the latter, 
repeated in an hour, offers us a very useful resource in the styptic 
influence of the acetate of lead. 

Infusion of red rose leaves, with elixir of vitriol ; powders composed 
of five or ten grains of sulphate of alumine, with a few grains of nut- 
meg ; and the application of cloths pressed out of cold vinegar and 
water to the pubes ; all these are measures that must be sometimes 
resorted to, when the flow of blood continues after the delivery of the 
secundines has taken place. 

Violent and dangerous effusions of blood sometimes come on soon 
after the delivery of the placenta, and at a time when the labor is sup- 
posed to have been terminated in the most successful and fortunate 
manner. If half an hour elapses after the delivery of the after-birth 
without any flooding, we shall rarely meet with it, and may, for the 
most part, consider the patient safe. Nevertheless it does, sometimes, 
come on many hours later ; or even many days are passed, without 
any apparent tendency to the accident, before the female is attacked. 

The causes of this bleeding are to be sought for in the relaxed 
state of the womb, arising from loss of power in its muscular portion. 
They are almost invariably connected with an excited and impetuous 
circulation, by which the blood is propelled w T ith such power and 
momentum into the uterine arteries, as to force open their extremities, 
when they are not sufficiently supported and constringed by the mus- 
cular contractility of the uterus. 

Such an attack ought to be foreseen, in the state of the pulse, and 
obviated by the use of such measures as may serve to abate the 
violence of the blood's motion; and the patient ought not to be 
abandoned by the physician, until he has become fully satisfied that 
the danger is past. Let the patient lie in a truly horizontal posture ; 



PRETERNATURAL LABOR. 395 

let blood be taken from the arm if required ; let cool drinks be given, 
and cold water applied to the face and forehead ; and let great care 
be taken to ascertain, from time to time, by the touch, externally, 
whether the womb is firmly condensed or not. It is not good, I think, 
to allow the napkins, that are often applied to the vulva, to be too 
firmly pressed to the parts; they serve, when so pressed, as a sort of 
tampon, which enforces the coagulation of the blood in the vagina, 
and that itself is often a dangerous tampon. The blood which cannot 
escape accumulates in the womb, and brings on a concealed hemor- 
rhage, that is likely to increase with a frightful rapidity that may 
sink the patient irrecoverably by the time it is discovered. When 
blood has once escaped from its vessels, it is of no further service in 
this case at least, and therefore, the sooner it is got rid of, the better 
for the sufferer. 

I have governed myself as much as possible by the rule acted on 
and enforced in his lectures by the late Professor James, which was, 
" Don't leave your patient for one hour after the termination of the 
labor." The pressure of business upon a medical man in a large 
practice will sometimes make it impossible to stay so long near the 
lying-in woman, but when under the necessity of leaving her, he 
ought always to make arrangements for his recall in case of need. 
Leaving a newly-delivered woman a few minutes after the deliver- 
ance, he exposes himself to the shock of hearing, upon his return to 
his house after one or two hours, that "Mrs. B. wants him imme- 
diately, as soon as possible — has sent again and again — they think 
she is dying!" 

I have many times been saluted with such messages, and it would 
be difficult to express the sensations they excite. It is true that most 
of the cases are neither fatal nor even dangerous, yet occasionally a 
woman is found to sink and die, almost without warning, from effu- 
sions of blood which either flow out upon the bed, or are retained 
within the vagina and womb, distending them enormously without 
giving rise to the least suspicion in the friends or nurse that the 
woman is bleeding. 

In case of being summoned in this sudden manner to return to the 
patient, it is obviously the first duty of the physician to make sure 
of the state of the womb ; and accordingly, as soon as he reaches the 
bedside, he should place his hand on the hypogastrium in order to 
learn whether the organ is too much distended : if it be found too large, 
his course is plain — he must break up the clots which fill it and press 
them out ; if it be not too much distended — and yet there are those 



396 PRETERNATURAL LABOR. 

signs of weakness "which show that the patient has lost too much 
blood while no great external or open flooding has taken place — he 
should still act as if there were really a hemorrhage. Let him then 
introduce one or two fingers into the vagina, and he will be almost 
sure to find that the tube is filled to distension with a very solid clot, 
a clot as large perhaps as a child's head, and extending up into the 
womb. Upon tearing this clot with his fingers and pressing at the 
same moment with the other hand on the lower part of the belly, 
exhorting the woman to bear down, the coagula are expelled with 
more or less violence, and the woman immediately expresses herself 
as relieved. I must reiterate in this place the injunction, never to 
forget that in uterine hemorrhage all proper measures must be taken 
to cause the womb to contract; never to forget that with a condensed 
womb there is no hemorrhage, nor that the womb will nearly with 
invariable certainty contract or condense itself, if some antagonist 
or distending force does not prevent. Remove or withdraw, therefore, 
the antagonist force, and the patient is saved. 

The bandage for the abdomen ought never to be omitted in these 
cases of flooding, for the belly being suddenly evacuated of the con- 
tents of the womb, there is produced a feeling of inanition and 
weakness, that often is, alone, able to bring on faintness, or a state 
approaching to it; and that is highly conducive to the increase of 
uterine hemorrhage. I have already, in my remarks on labors, 
spoken on this topic, and will refer my readers to pages 310 and 312 
of this volume. 

I have long been impressed with the beautiful simplicity and the 
truth of the following affecting story, from the pen of the celebrated 
Mauriceau ; and as his writings are little known in the United States, 
I have, on that account, as w 7 ell as for the intrinsic practical import- 
ance of the case, resolved to translate it for this part of my work. 
Those who read it will, as I think, agree with me, that it conveys 
a most instructive lesson to the student of midwifery, and, if I am 
not mistaken, will need no other apology for its introduction here. 

"Many women (says Mauriceau, liv. 1, p. 158) have perished, 
together w T ith their offspring, for want of prompt assistance on such 
occasions [hemorrhage] : and not a few have escaped from an other- 
wise inevitable death by early succor; while their children have re- 
ceived the holy sacrament of baptism, of which, but for that aid, they 
would have been deprived. Guillemeau, in liv. 2, chap. 13, of his De 
V Accouchement, mentions six or seven cases confirmatory of this truth, 
in most of which it is seen that both the mothers and their children 



PRETERNATURAL LABOR. 397 

were the bloody victims of want of promptitude in delivery under 
such circumstances, while some of them escaped in consequence of 
early assistance ; but, that I may confirm this doctrine by the results 
of my own experience, I shall relate one case, among many, that is 
very remarkable ; and the remembrance of which is so vividly im- 
pressed upon me, that the very ink with which I now am writing, in 
order to make it known for the benefit of the public, seems to me to 
be turned into blood; for on that piteous and fatal occasion, I wit- 
nessed the effusion of a part of my own vital fluid, or, to speak more 
correctly, the whole of what resembled the blood of my own veins. 
"It was sixteen years ago that my sister, who was not yet quite 
twenty-one years of age, about eight months and a half gone with 
her fifth child, being at the time in excellent health, was so unfortu- 
nate as to hurt herself, though, to all appearance, very slightly, by a 
fall on her knees, the belly at the time striking the ground ; subse- 
quent to which she passed a day or two without experiencing any 
considerable inconvenience, so that she neglected to keep herself as 
quiet as she ought to have done ; but on the third day, at about eleven 
o'clock in the morning, she was suddenly seized with strong and fre- 
quent pains of the belly, which were also accompanied by a great 
discharge of blood from the vagina. She immediately sent for the 
midwife, who was not too well versed in her occupation, and who, 
when she arrived, informed my sister that it was necessary, before 
delivering her, to wait until the pains should spontaneously open the 
mouth of the womb, assuring her, that she had nothing to fear from 
the accident, and would be soon delivered, because the child pre- 
sented very favorably. In this way she fed her with vain hopes for 
three or four hours, until, the flow of blood continuing very great, the 
pains began to leave her, and the poor lady fainted away several 
times ; upon seeing which, the midwife requested that a surgeon might 
be sent for to assist her. They came immediately to my house, to 
notify me of the affair; but being unhappily from home, they called 
in one, who, they supposed, was one of the ablest obstetricians or 
surgeons in the whole city at that period, and he was immediately 
taken to my sister's residence, where he arrived about four o'clock 
in the afternoon. Having seen the state she was in, he contented 
himself with merely saying that she was a dead woman, for whom 
nothing was wanting but the last sacraments of the church, and that 
it was absolutely impossible to deliver her. To all this the midwife 
readily agreed, for she thought the opinion of this man, so universally 
esteemed, must be, beyond doubt, correct. As soon as he had pro- 



398 PRETERNATURAL LABOR. 

nounced his judgment, he went away, refusing to stay any longer ; 
and in this deplorable condition, and without offering the smallest 
succor, he left this female, whose life, as well as that of her child, he 
could certainly have saved, had he delivered her then, which he might 
easily have done, as will be seen by the sequel of this history. 

"After the judgment of a person of such great reputation, added 
to that of the midwife, every one who was present thought that since 

M. could do nothing for her, there could be no other recourse, 

in so great a misfortune, than placing confidence in God, to whom 
alone everything is possible. 

" They now endeavored, as well as they could, to console my 
poor sister, who with a passionate earnestness desired to see me, that 
she might know whether I also would pronounce the same judgment 
upon her; and whether her disease, which was constantly growing 
worse, was beyond all remedy ; for her blood was steadily flowing in 
great abundance. At last, I returned to my house, where they had 
been a long time before, to tell me this bad news; and where, most 
unfortunately, I w^as not to be found at the time, as I have already 
related. As soon as I heard of it, I hastened to her house, and upon 
arriving there, I saw so piteous a spectacle, that all the passions of 
my soul were agitated at the sight, with many and different emotions ; 
after which, having somewhat recovered my composure, I approached 
the bed of my sister, who had just received the last sacraments; and 
being there, she implored me again and again to assist her, saying, 
that she had no hope but in me. After I had learned from the mid- 
wife all that had happened, and she had told me of the opinion of the 
surgeon, who had seen her more than two hours before, for it was 
now past six o'clock, I perceived that the blood still continued to 
flow profusely, and without ceasing, though she had already lost more 
than three quarts, and, what is remarkable, more than forty-eight 
ounces wuthin the two hours since the surgeon left her — as I supposed 
from the quantity of the napkins and cloths which were all saturated 
with it; which blood, by remaining in her body, had she been time- 
ously delivered, w r ould, beyond doubt, have saved her life. I also 
saw that she was seized almost every minute with sinking turns, that 
were increasing; which convinced me that she was in far greater 
peril than she could have been had they not lost the opportunity of 
delivering her two or three hours sooner, which w T as both possible 
and of easy execution ; for at that time she had almost the whole of 
her strength, w T hich she afterwards lost by the continual effusion of 
her blood. Wishing to know whether it was true that she could not 



PRETERNATURAL LABOR. 399 

be delivered, I found, upon examination per vaginam, the orifice of 
the womb dilated, so as easily to admit two or three fingers. Having 
remarked this, I made the midwife examine her again, in order to 
ascertain whether the os uteri had been in the same state when the 
surgeon stated that she could not be delivered; and whether she was 
still of his opinion: she told me ' Yes,' and that the parts had re- 
mained unchanged ever since he had gone away. As soon as she 
made this declaration, I perceived her ignorance, and what had been 
the difficulty with the surgeon. Touching this, I told her of my as- 
tonishment that they had both been of such an opinion, as I was of 
a wholly different opinion — for it would have been as easy for him to 
deliver her then as now; which I should, in truth, have immediately 
done myself, could I possibly have commanded my judgment, long 
vacillating upon this resolution, which, from the loss of all hope from 
other quarters, I was at last constrained to adopt. What hindered 
me was, not the prognostic of the surgeon, celebrated as he was, 
w T ho had persuaded everybody that to deliver her was impossible, 
(for it would seem like rashness to resist the dicta of those w T ho are 
looked upon as oracles,) nor the weakness of the patient ; but it was 
chiefly the quality of the person, who was my own sister, and whom 
I tenderly loved, that agitated my mind with various passions. For 
my mind was so preoccupied with seeing her ready to expire before 
my eyes, from the prodigious waste of that blood that sprung from 
the same source as my own, as to make it impossible for me to come 
to an immediate resolution and action. This obliged me to send in- 
continently for the surgeon, who had left her so long before, and beg 
him to return to her house, so that I might show him how easily she 
could be delivered — and by making him understand and confess that 
there is no hope on such occasions except in prompt delivery, induce 
him to operate, instead of leaving the mother, as he had done, to 
despair, and allowing her infant to perish without baptism, which it 
might have enjoyed had he obeyed the requirements of the art, which 
are, that if both cannot be saved, we should, at least, try to save the 
child, if that be possible without doing anything prejudicial to the 
mother. But he would not come back for all the prayers and solici- 
tations that could be offered; and excused himself by saying, that it 
would be impossible to do anything in such a situation. As soon as 
I learned all these things, I sent for another surgeon, w T ith whom, had 
he come in time, I should have concluded in favor of the necessity of 
the operation, of the possibility of which I could have satisfied him ; 
but, as misfortune would have it, he was absent from home. Mean- 



400 PRETERNATURAL LABOR. 

while, at least an hour and a half more elapsed, during which the 
blood was incessantly flowing, and the faintness increasing more and 
more. Finding myself, therefore, hopeless of the aid of the persons 
I had sent for, I resolved to deliver her myself immediately, for I had 
not been able to resolve upon it, except in this extreme necessity, 
for the reasons already given; which, indeed, was somewhat too late 
for the mother; for, had I been able to command myself sufficiently to 
proceed to the delivery at my first arrival, there was great reason to 
hope for her safety, as it afterwards proved as to her child, when I 
had completed the task in the following manner : — 

" I introduced two fingers into the orifice of the womb, which was 
open enough to receive them ; I then gradually inserted a third, and 
little by little, the ends of all the fingers of my right hand, with which 
I so dilated the orifice as to admit the whole hand, which is readily 
to be done on such occasions, because, as has been already said, the 
abundant discharge of blood moistens and relaxes the entire womb 
very much. Having introduced my hand very gently, I found that 
the head of the child presented, and that the waters were not yet gone 
off, which obliged me to break the membranes with my finger nails. 
Having done this, I immediately turned the child so as to draw it 
down by the feet, which I easily effected, as I shall describe the ope- 
ration in the 13th chapter of the second book. The operation was 
effected in less time than it takes to count a hundred, and I protest 
upon my conscience, that I never in my life performed an accouche- 
ment (of a preternatural case) with greater ease and expedition, or 
less pain to the mother, who never complained in the least during 
the operation, notwithstanding she then was quite herself, and knew 
perfectly well what I was doing. Indeed she found herself quite 
relieved, as soon as I had delivered her, whereupon the flow of blood 
began to cease. 

"As to the child, I delivered it alive, and it was instantly baptized 
by a priest who was in the chamber. The patient, and all the by- 
standers, who were numerous, then perceived very clearly that the 
surgeon and midwife, who had pronounced it impossible to deliver 
her, had done so without any good reason. 

" The operation was performed in good time to procure baptism 
for the child, who received it, praise be to God, as I just now said ; 
but it was too late to save the life of its mother, who died an hour 
after its birth, in consequence of having lost too great a quantity of 
blood, for she fell into a great swoon, like those she had had pre- 
viously to the delivery. The flow of blood ceased, it is true, but 



PRETERNATURAL LABOR. 401 

there was not enough left in her body to resist these frequent syncopes, 
which she could doubtless have done, had the surgeon, who saw her 
first, delivered her three full hours earlier, as he could have done, 
without doubt, as easily as I did it; since which time she had lost, 
without exaggeration, more than eighty ounces of blood, twenty of 
which, had it been reserved, would have insured her escape ; particu- 
larly, as she was a young woman, of a good constitution, free from 
all disease or inconvenience at the time she was attacked by this 
fatal accident, which happened, as before said, at eleven o'clock in 
the morning. She was delivered at seven in the evening; but the 
operation was unsuccessful for her, because she had been drained of 
blood: she died an hour afterwards, in full possession of her senses, 
and speaking until the last moment of her existence, which was at 
eight o'clock, P. M." 

Convulsions. — Among the severe and dangerous disorders to which 
pregnant and parturient women are liable, may be classed the puer- 
peral convulsion, as one of the most dreadful. It never occurs without 
carrying dismay among all those w r ho take a near interest in the 
patient; whom it exposes to the greatest risk, by the violent affections 
of the brain with which it is connected. 

Dr. Collins {Practical Treatise, p. 199), says, "there are few cir- 
cumstances more calculated to alarm the practitioner or excite terror 
in the friends of the patient, than the occurrence of convulsions dur- 
ing the progress of labor; and the result both with regard to the mother 
and child proves the danger serious." 

I have already spoken, in a former page, of the excited state of the 
blood-vessels that accompanies labor, and I think, that, in view of 
the rapidity and momentum of the circulation produced by that state, 
no surprise ought to be felt at the occasional appearance of convul- 
sions. 

If the extreme violence with which the blood rushes during labor 
along the arteries of the encephalon, be taken into consideration, it 
will be seen that the brain must, in such an excited circulation, be 
brought into a state of the highest nervous activity, and the function 
of innervation become so considerably and irregularly augmented, in 
consequence, that the muscles of the body fall readily into convulsive 
movements. The activity of the functions of the brain and spinal 
marrow is always increased, proportionally, with the quantity of blood 
circulating through those structures ; a woman, therefore, in whom 
the pulse is uncommonly hard, frequent and large, ought, cceteris 
26 



402 PRETERNATURAL LABOR. 

pmibus, to be more obnoxious to the convulsion than a woman in a 
directly opposite state. Accordingly, I think it will be very rare to 
meet with the malady, except in such as have a very bounding and 
tense pulse. Let it be early obviated. 

The long-continued pressure of the womb upon the great vessels 
in the abdomen, cannot fail, in some women, to retard, to a certain 
extent, the flow of the blood in the branches of the aorta below the 
point compressed by the womb, as has most judiciously been observed 
by Puzos, and we daily witness the effect of that pressure on the veins 
and absorbents, in the temporary varices of the veins, and in the 
cedematous limbs, of the later stages of pregnancy; which symptoms 
are observed to vanish with the removal of the cause of pressure. 
This removal takes place by the birth of the child, and the subsidence 
of the womb into the excavation of the pelvis, after delivery. The 
same causes of pressure, by impeding, in any degree, the downward 
flow of the aortic blood, must give to the mass of blood a disposition 
to mount upwards, and linger in the vessels of the brain and upper 
parts of the body. They occasion a congestion and irritation of the 
brain, characterized by headache, confusion of thought, vertigo and 
delirium, resulting in convulsion or apoplexy. The merest tendency 
to such results is worthy of the most solicitous regard and anxious 
attention. Let a pregnant woman acquire the habit of congestion in 
the brain, and if, as soon as the efforts of labor come to superadd their 
power to a dangerous predisposition, we omit all regard and care for 
such symptoms, there will be more than a probability of our having 
to contend with the disorder now under consideration. 

It is far better to ward off than to cure an attack of puerperal con- 
vulsion. No one can look upon the case, with due comprehension of 
its nature, and not fear that a fatal effusion or extravasation will take 
place during the attack. It is very well known, that not a few instances 
do occur wherein the fatal blow is struck at the very onset, and that 
some women never speak, nor exhibit the smallest sign of reason or 
sensation from the moment of invasion, but sink at once into the ster- 
torous apoplectic sleep that leads rapidly to the sleep of death. 

The state of pregnancy, for some women of a very irritable consti- 
tution, is rather a pathological than a physiological condition. The 
woman labors under constitutional irritation from the commencement 
of her pregnancy, and never feels well until she is delivered. She is 
fretful and peevish ; ceases to be amiable ; and after the conservative 
powers of the constitution are at last defeated and overthrown, the 
fruits of the disorder are seen in puerperal insanity or convulsions. 
Such a state both causes and maintains a vitiated condition of the cir- 



PRETERNATURAL LABOR. 403 

culation, which should be met by venesections, repeated according to 
the enlightened judgment of the medical attendant, by purgatives or 
aperients; by counter-irritants : by a judiciously regulated diet; by 
regulated exercise; by baths; by proper clothing; and by the removal 
or prevention of all causes of mental solicitude or excitement. But in 
order to the suitable prescription of all these agents, the physician ought 
to see the patient occasionally, before the completion of her term. 
Hence, the public ought to know, that counsel should be taken of the 
physician, from time to time, for all pregnant females who do not enjoy 
good health during gestation. If such counsel were sought for at an 
early period, the attack of convulsion would not, in general, take place. 
Most of the cases come on when not in the least expected or antici- 
pated, and, as I have already expressed it, "the fatal blow" is the 
first and the last one; the patient sinks at once into coma, and dies, 
without ever recovering her senses. 

The attack of convulsions has been supposed to have some con- 
nection with the irritation of the nervous system occasioned by the 
dilatation of the os uteri. Possibly this may in some examples be 
true. We meet with many cases where the os uteri is fully dilated 
before the seizure, and a small proportion are met with in persons 
who have already been delivered. At page 200, Dr. Collins, in speak- 
ing upon the idea that the dilatation of the os uteri is causative of the 
disorder, says, "This fact might be brought forward to support the 
opinion, that puerperal convulsions were caused by the irritation pro- 
duced in the dilatation of the mouth of the womb. This, however, 
is not the case, as we not unfrequently find patients attacked when 
the os uteri is completely dilated and all the soft parts relaxed. I 
conceive we are quite ignorant as yet of what the cause may be ; nor 
could I ever find, on dissection, any appearance to enable me to even 
hazard an opinion on the subject." 

Since the introduction of ether-inhalation in Surgery, and the pro- 
posal to use it in midwifery, the anaesthetic powers of the ether and 
other articles employed in that way have served to shed no little light 
upon the state of the brain in our eclampsia. In my " Letters to the 
Class," sub voce, I have expressed my views upon the nature of the 
alterations discoverable in the functions of different parts of the en- 
cephalon during eclampsia. 

While I admit that the attack, or onset, is caused by long-continued 
determination to the head by the rapid revolution of the blood, excited 
by labor, or by the too intense perception of the pains of labor, I 
conclude that the profound insensibility ought to be regarded as an 



404 PRETERNATURAL LABOR. 

anaesthesia caused by the presence of much black blood in the brain ; 
that when the black blood grows blacker and blacker, so as to 
render the patient dark as an Ethiop, the convulsion is nearer and 
nearer to its close; that as soon as the black blood comes to cir- 
culate freely in the cerebellum, the convulsions cease — and that if it 
pervades the medulla oblongata, the patient dies for want of power in 
the sources of the vagus nerve. An individual perishes very soon 
from inhaling ether or chloroform, which is capable in certain persons 
of carrying its anaesthetic force first upon the respiratory brain. But, 
if the respiratory brain forget to cause the respiration! 

The author before cited, Dr. Collins, in a foot note on p. 200, 
states, "that of nineteen cases recorded by Dr. Joseph Clarke, sixteen 
were first children. Of thirty-six by Dr. Merriman, twenty-eight were 
first children. Of thirty by himself, twenty-nine were first children. 
So that of the eighty-five cases, seventy-three were first pregnancies." 
In seventeen cases of convulsions under my own notice, ten were first 
pregnancies, and one not known. 

Under the dreadful circumstances of this disorder, one reflection 
ought to strike very obviously the mind of the medical attendant; it 
is, that if the woman were not pregnant, she would not be assailed 
by the disease; and the inference very justly follows, namely, the 
pregnancy ought to be terminated in order to put a stop to the malady. 
For whether the assault has depended remotely on mere pressure on 
the great vessels, or on that more metaphysical state called sympathy 
of the brain and womb, we shall enjoy a far better prospect of rescuing 
the woman if she can be delivered, than we shall if the womb remains 
unemptied. 

But can we deliver — ought we to deliver — when and how shall 
we deliver, the woman? We can deliver if the womb is dilated or 
dilatable. We ought to deliver provided we find that the discordant 
operations of the womb and constitution are likely to fail of bringing 
the child into the world : for although the womb sometimes acts with 
great power during convulsion, and is successfully aided by the vio- 
lent, irregular and spasmodic constriction of the abdominal muscles, 
and other accessory forces of parturition; it also happens, that the 
child, in some other instances, makes no progress at all, and the con- 
vulsions return at short intervals, affording but smallprospect of escape 
for the patient, inasmuch as they will be likely to continue until the 
pregnancy is brought to a close by the delivery of the entire ovum. 

It is, therefore, always desirable that the patient should enjoy the 
benefits of as early an accouchement as possible, but it must never 



PRETERNATURAL LABOR. 405 

be forgotten that the attempt to effect it must be regulated, entirely, 
by the fitness of the parts for the operation. There can be no excuse 
for forcing the hand into an undilatable os uteri, under any circum- 
stances; and if the medical attendant be ever so anxious to give his 
patient every possible chance of safety, he will not be excusable, if, 
on that account, he rather adds to, than diminishes, the risks of her 
frightful disorder, by intempestive violence in the introduction of his 
hand. It is true to say that " anceps remedium melius quam nullum ;' ' 
but let not this trite aphorism lead us to the commission of positive mis- 
chief, under the impression that we are about to emply a doubtful 
remedy. Happily for us, however, delivery is not the only resource 
to which we can apply in our anxious wish to put an end to the danger 
and distress of the scene before us. What are the circumstances of 
the case? The patient has, perhaps, complained of severe pain in 
the head; she is under the excitement of labor; she is heated; the 
pulse is hard, full and bounding, and greatly accelerated. On a 
sudden, the muscles of the whole body become convulsed, and the 
patient writhes, and every feature and every gesture are horribly 
distorted; the respiration is attended with a hissing noise, and froth 
issues with violence from betwixt the teeth, which are firmly closed 
by spasm, giving rise to the peculiar hissing sound above mentioned. 
The eyes are rolled upwards, or moved in opposite directions; and 
after a greater or less duration of the paroxysm, the patient sinks into 
a stertorous sleep, or profound coma, from which she is roused only 
by a renewal of the convulsive movements, or to mutter in the in- 
tervals incoherent or inarticulate sounds. Here, then, we have the 
proofs, as they are the results, of a preternaturnl development of the 
innervating functions of the brain and spinal marrow, which are 
caused or maintained by an undue momentum of the cerebral cir- 
culation. The remedy is, first, to remove the cause by delivery ; and 
second, to moderate the effect by venesection and evacuants. By 
the abstraction of blood, we can weaken the force of the circulation 
of the whole system ; we can make the heart beat gently, and cause 
it to send the blood in a milder current into the vessels of the brain ; 
we can thus diminish the innervative function of that organ, and 
control the muscular excitement, while, at the same time, we abate 
the hazard of extravasations of blood taking place in the substance 
of the brain, or of the effusion of water into its ventricles. If there 
be a case of disease in which bold and daring employment of the 
lancet is demanded, it is the case of the puerperal convulsion. It is 
scarcely worth while, almost, to open a vessel to draw off eight or 



406 PRETERNATURAL LABOR. 

twelve ounces of blood. The patient ought to lose from thirty to 
sixty ounces at one venesection, if possible; and if signs of faintness 
appear, they should be hailed as the harbingers of success. They 
will not appear, unless the brain is already, in some measure, freed 
from its state of tension; unless the blood is no longer pushed upon 
it with such force as to excite it beyond measure ; and if the mischief 
at the onset was not too great, there will be a greater chance of saving 
the patient provided they come on. 

While we endeavor by the use of the lancet to diminish the mo- 
mentum of the mass of the blood, which is propelled in vast quantities 
upon the brain,. we ought not to omit the use of other available means 
of moderating the turgescence of the vessels of that important organ. 
The general bleeding should be followed, very soon, by the applica- 
tion of cups to the temples and back part of the neck, and the hair 
ought to be cut off, and shaved clean, so as to admit of the application 
of leeches to the scalp, and the subsequent use of ablutions of the 
head with iced water and vinegar; or the use of an epispastic, with 
which the scalp should be covered, if the coma and other symptoms 
of local disorder are not in a favorable train of abatement. Sinapisms 
ought to be freely applied to the lower extremities, and to the abdo- 
men; and the location of them should be changed, from time to time, 
so as to keep up a constant irritation of some distant part, with a view 
of diverting the sanguine mass from the cerebrum. Enemata of salt 
and water, or of jalap mixed with water, may be made occasionally, 
as a further means of diversion to a safer part of the body. During 
the administration of so energetic an antiphlogistic treatment, it is in 
course to observe the most rigorous regimen : indeed, until the dan- 
gerous symptoms are gone off, very little aliment is admissible : solu- 
tions of gum, portions of barley or rice water, and where absolute 
weakness demands it, sago or arrowroot jellies, may be given occa- 
sionally, yet with great caution. Darkness, repose, silence, should 
all be considered essential prescriptions, in a case where so important 
an organ as the brain is concerned, and where the slightest irritations 
are sufficient to turn the scale in an unfavorable manner. 

Long-continued ill health may be, in general, expected to follow 
severe attacks of puerperal convulsions : and nothing but the most 
constant care and watchfulness can avert many evil affections, the 
sequelae of a state the most unnatural and trying to which the female 
constitution is obnoxious. 

I shall relate some cases of puerperal convulsions that have fallen 
under my notice, with a view to illustrate for the Student the mode of 



PRETERNATURAL LABOR. 407 

proceeding under such circumstances. I find in my case-book the 
following entry, for example : 

Case.— March 13th, 1838.— Mrs. M. in labor, first pregnancy. 
I was called on Sunday night, at two o'clock. She lacked fifty-nine 
days to the completion of her term ; was in strong labor pains, evidently 
of the dilating kind. They returned every five or six minutes. She 
was sitting up in a chair with her hands very cold, complaining of 
intense pain of the head. The pulse was very large, and as hard a 
one as I ever felt ; it beat one hundred and fifteen times in a minute. 
In consequence, of the circumstances above mentioned, I bled her to 
the amount of fourteen or fifteen ounces : upon which the pulse was 
softened, and the headache became milder. It had been most violent 
at the inferior occipital region, which it now abandoned in order to 
occupy the forehead, temples and crown. Notwithstanding the bowels 
had been moved, I gave her some magnesia, seeing she had vomited 
several times ; hoping that some alvine discharges would assist in calm- 
ing the violent disturbance of the circulation to the brain. 

In the morning she got an enema which operated freely, yet the 
headache continued to be severe, and the pulse somewhat tense. 
There w 7 as not a great degree of heat, and I expected to find a dimi- 
nution of the vascular excitement from a severe flooding, which came 
on at eight o'clock. At nine A. M., the os uteri was about the size 
of a dollar, hard and unyielding. 

At twelve o'clock my patient complained of severe pain in the head, 
and said to me, "I can't see you; I feel quite confused." As soon 
as these symptoms were made known to me, I was fearful of the ap- 
proach of a convulsion, and immediately proceeded to tie up the arm ; 
but before the blood began to flow from the vein, which was opened, 
she had a most violent convulsion. I allowed the blood to flow until 
the pulse became reduced, and then the convulsion went off. I did 
not take more than eight or ten ounces, which was a very small quan- 
tity, in view of the effect to be produced, and actually produced by 

the operation. Sinapisms were applied to the feet. Mrs. 

remained in a state of insensibility for twenty or thirty minutes after 
the disappearance of the convulsive movements, and then recovered 
her senses. She now had a very considerable flooding, which con- 
tinued to trouble her during the morning. 

As soon as the spasms ceased, I ruptured the membranes, and the 
foetus, which was dead, was expelled at half-past twelve o'clock. It 
was living at seven in the morning. 



408 PRETERNATURAL LABOR. 

She had no more spasms or convulsions after this, but the pain, 
like a clou (or nail in the head), was so violent that I ordered leeches 
to the temples in the afternoon, and gave her a proper dose of salts 
and magnesia. The pulse continued to abate of its violence regularly. 
The medicine operated freely ; but at seven o'clock the following 
morning, she was leeched again on account of pain in the head, and 
was perfectly comfortable from that time. This woman was dressed 
and walking the floor within four days after her accouchement. 

As regards this case, I presume any one of my fellow practitioners 
would readily say that it was well managed, notwithstanding the 
smallness of the second bleeding, since I resorted early and promptly 
to the use of proper remedies. I conceive that the resort to venesec- 
tion in the first visit was highly expedient, and though it did not 
ward off the threatened convulsion, it doubtless mitigated it, and 
rendered it more manageable by the subsequent treatment. The only 
real resource in the puerperal convulsion, is in the use of the lancet; 
and the rule ought to be established, that a woman is menaced with 
convulsions, if she is affected with headache near her term, especially 
if that headache be referred to the crown, or to some point (clou) that 
could be covered with the end of the finger. I intend never to hear 
such complaint without pondering upon the value of the indication it 
throws out, namely, that the lancet, the lancet, and nothing but the 
lancet, is worth your confidence. I shall make these same reflections 
in similar circumstances of pregnancy even when not advanced be- 
yond the sixth month, having lately had occasion to witness a despe- 
rate attack in a young primipara five months gone in her gestation. 

Case.— March 13th, 1838, called to Mrs. at six o'clock 

this evening. She was sitting in her parlor. She expects her labor 
every hour, the time being out. 

I said, " How d'ye do?" " I feel weak," she replied. "I can- 
not see more than half of anything I look at; I can only see one-half 
of your face: I can see only one of your eyes." I asked her to cover 
her right eye with her hand. " Can you see the whole of my face 
now ?" " No!" " Cover your left eye ; can you see properly now ?" 
"No; I can see only half." "Have you any pain, weight or dizzi- 
ness of the head ?" "No!" "Any sick stomach?" "No!" "How 
long have you been so?" "About half an hour!" " Were you 
ever so before?" "No!" "Any numbness or want of feeling in 
the hands?" "No; but my hands are cold." The pulse was about 



PRETERNATURAL LABOR. 409 

eighty-five, and a little tense, yet moderately so. The bowels not 
bound. 

She now went up stairs, and I took four ounces of blood from the 
arm, having bled her eight ounces six days ago: when I had bled 
her she could see the whole of my face, or the whole of any object 
she looked at. She did well. 

It is also a curious circumstance, and one well worthy of your 
attention, that the blackening of the blood, or its conversion into 
venous blood by the interruption of the respiratory or oxygenating 
function, should be the means provided and designed by Providence 
for the cure of the paroxysm. When the whole sanguine mass has 
become carbonated, the brain and the spinal cord must cease to 
innervate the muscles convulsively; and the speedy relaxation of 
every rigid muscle permits the restoration to the lungs of their oxy- 
genating power ; so that, in a few moments after the countenance has 
been black and deformed in every feature, we have the pleasure to 
see it recover its whiteness, though ghastly pale ; while the brain, I 
mean the whole brain, wakes up to the renewed performance of its 
organic as well as its intellectual offices. When, therefore, in look- 
ing upon these frightful scenes, you see the face of your patient grow- 
ing darker and darker, you will discover in that very circumstance, 
the hopeful announcement of a speedy close of the distressing exhi- 
bition. 

I think that, in a majority of cases, you may expect to find the 
whole brain recover soon after the ceasing of the convulsive innerva- 
tions; but this is not always the case; for, in some patients, I have 
noticed a profound coma to succeed the convulsions; the hemispheres, 
the cerebellum, and the tubercula quadrigemina, remaining oppressed 
and extinct, as to the power, while the medulla oblongata and the 
spinal cord had resumed a quasi regular exercise of their forces. 

In a case that fell under my care in this city, a few years since, the 
lady had convulsions, which occupied the hours from about 11 o'clock 
A. M. till near 5 P. M. During these convulsions she gave birth to a 
dead foetus of seven months; remaining wholly unconscious during 
the process. I say unconscious, though she moaned a little, during 
the labor pains, like a person disturbed by some distressing dream, 
or like one under the influence of ether in a surgical operation. Some 
hours after the last convulsive attack, and after she had been lying 
profoundly still, as if asleep, she moved with spontaneous or voluntary 
motion, showing that the cerebellum was aroused to its true office of 
directing or co-ordinating the power extricated in the brain and spinal 



410 PRETERNATURAL LABOR. 

cord. She soon afterwards spoke and recognized the Toices of 
friends, and was perfectly reasonable ; showing that her hemispheres 
had waked up to their office of intellectual perception and combina- 
tion. After having for some time spoken, and spoken well, she said, 
" How dark it is — why do you keep it so dark ? " " It is not dark," 
replied I ; " do you not see the candle?" " Oh no, there is no candle 

here." " Yes, dear Mrs. , here is the candle ; see — I hold it just 

before your face." Her beautiful eyes were open, and she turned 
them at will, to look for the light which shone into their large dark 
pupils. " Do you not see the light?" said I again. " Oh no, Doctor ; 
why do you say so? I'm sure there's no light here." She was totally 
blind : that is to say, hertubercula quadrigemina were still oppressed, 
while the rest of her brain had recovered, being liberated from the 
thraldom of the congestion. After some time, the dawning light of 
day having considerably increased, she perceived it, and cried out, 
" Why, it's daylight!" and I then knew that the tubercula quadrige- 
mina had also recovered. 

There is a useful moral in this statement — it is that we should look 
to it, in the conduct of all such cases of disease, that all the parts of 
the brain recover — and that in so far as our measures may have effi- 
cacy, we fail not to employ them to the entire subduction of even the 
last vestiges of morbid action, or oppressed or suspended power. 
These vestiges of disease we may clearly discern in the intellection, 
and in the muscular innervations. 

The successive recovery of the different parts of the brain in this 
case is interesting, as it is analogous to the incidents observable under 
etherization. When a patient is subjected to the inhalation of ether, 
the different parts of the brain are affected in succession ; but not 
always in the same succession. The sensitive cords of the cerebro- 
spinal axis are, in etherization, plunged into a state of insensibility — 
leaving the hemispheres capable to perceive and understand what the 
quadrigeminal tubercles see of any operation that the surgeon is per- 
forming. Or, the motor fibres are put asleep, yet the sensitive ones 
communicate to the conscious mind the painful impressions which the 
mind perceives — but which it forgets, as it forgets a painful dream. 

If the etherization go very far, the hemispheres, the cerebellum, 
the tubercles, and the motor and sensitive cords, are all hushed in a 
profound state of aperception, both of the direct and the reflex influ- 
ences or impressions: the medulla oblongata alone continues to do 
its work of irradiating the parts that are under the control of the 
pneumogastric. If the ether be given long enough, and in quantity 



PRETERNATURAL LABOR. 411 

sufficiently great to quell its force of innervation also, the patient 
dies. Hence the medulla oblongata is called by M. Flourens the 
life-tie — the vital knot — le nceud-vital. The oxygenating power 
depends upon it, and without oxygen — no neurosity. Take away the 
ether in good time ; admit the pure atmosphere to the lungs, and the 
functions of the whole brain are revived — so, in our eclampsia, as soon 
as the abnormal state of the encephalic circulation gives place to a 
normal, or, one more nearly normal, the brain wakes up to its duties 
again, and the patient sees, hears, speaks and acts, with the most 
perfect co-ordination of all those vital forces that are dependent on 
the brain and cord. 

If, in etherization, we press the administration of the drug to the 
point of quelling the vital-tie of the medulla oblongata, she will die, 
and we will find no neucroscopic lesions in the encephalon. So, 
likewise, in the speedy dissolution under eclampsia puerperalis ; the 
autopsia discloses no lesion of any part of the brain. Are we sur- 
prised that the woman should die without perceptible physical lesions 
of the brain? We are not at all surprised if she disclose none such 
when destroyed by ether-inhalation. May not the brain perish under 
the one influence as well as under the other, and yet, dying, leave no 
sign ? In eclampsia, there is always abolition, for the moment, of 
the power of the hemispheres, always of the tubercula quadrigemina, 
and always (perhaps!) of the cerebellum. All these revive, and are 
extinguished again and again, as the paroxysms are repeated or sus- 
pended by turns. When the case has come to its close, and the patient 
is restored, where are the lesions ? No trace of them remains. But — 
and here is the explanation — if the medulla oblongata be affected 
equally with the others, the patient dies, because the sources of the 
respiration are cut off. 

There are many circumstances, the concurrence of which tends to 
the development of the eclampsic convulsions of pregnant, puerperal, 
and lying-in women. For many women, the whole state of gestation 
from conception to labor, is a state of nervous excitement or hyper- 
esthesia, which renders the subject specially obnoxious, under the 
application of exciting causes, to convulsive or irregular, non-con- 
formable innervation. Whether this too susceptible nature depends 
upon an altered crasis of the neurine, or whether it arises from modi- 
fications of the blood, developed during the gravidity, remains to be 
ascertained ; and it contains questions full of interest to the patholo- 
gist and the therapeutist. 



412 ' PRETERNATURAL LABOR. 

• 

Cramp. — I do not remember to have met with any published state- 
ment of cases of cramp in the legs as causes of Preternatural labor, 
and yet having met with examples of it in my own practice which 
rendered the use of forceps absolutely indispensable, I have thought 
fit to relate them in this book. There is no need for great surprise 
at the announcement of this cause of preternatural labor, since it is 
well known that the compression or tension of a nerve may give rise 
to pain so great as to disturb in the most violent manner the functions 
of life. The head of the foetus in descending may be impelled with 
so great a degree of force against certain of the internal sacral nerves, 
as to render the patient almost or quite frantic from the agonizing sen- 
sations developed thereby. Under such intense suffering, the womb 
may cease to act, or act inefficiently, and the practitioner, seeing that 
the distress of his patient is greater than she should be permitted to 
bear, hastens to extend to her the most prompt and efficient means of 
relief. 

Without further discussions of the reasons which, a priori, should 
include the violent cramps to which I refer, among the causes of pre- 
ternatural labor, I beg to refer the Student back to page 29, for ac- 
counts of the cases, which I have no occasion to repeat in this con- 
nection. 

Prolapse of the Cord. — There are other circumstances that may 
suffice to convert a natural into a preternatural labor. Among these 
may be mentioned the prolapsion of the umbilical cord. The cord 
very rarely gets down below the presenting part of the child, and we 
have reason to be astonished at the rareness of the accident, when we 
consider the great length of that part of the secundines. The cord is 
sometimes found to be six feet in length. The mere falling of the 
cord could not, under any circumstances, interfere with the ability of 
the woman to deliver herself, because it could not inconveniently oc- 
cupy any space in the pelvis to the hinderance of the birth. The 
importance of the accident is relative only to the child, and not to the 
mother. The child is placed in imminent danger of dying by as- 
phyxia, from pressure on its umbilical vein and arteries when they 
fall below its head in labor. Hence, the necessity of expediting the 
delivery by manual or instrumental means, and the conversion of the 
natural into the preternatural kind of labor, either by turning or the 
forceps. 

I do not wish to be understood as advising a resort to art as an 



PRETERNATURAL LABOR. 413 

invariable rule of practice in such cases; for it fortunately happens, 
In some instances, that the pelvis is large and roomy, the os uteri 
dilates rapidly, and the pains are sufficiently strong to assure us that 
the child will be born so speedily by the unaided powers of nature, 
as to make it unnecessary for us to interfere. The child has so good 
a chance for escaping uninjured, in a rapid delivery, that it is more 
advisable to confide in that chance, than to expose both the woman 
and the child to the hazards of a forced delivery. We also have the 
advantage of being able, by touching the prolapsed cord, to ascertain 
the state of the foetus : if the pulsations continue vigorous, we shall 
suppose the child to be doing well, and if they become faint and 
feeble, we shall be able to resort to the forceps or to turning, as the 
case may be. When the prolapsed cord has no pulsation and is cold, 
the child is dead, and of course no steps need be taken on account 
of the prolapsion, which, in that case, becomes a matter of indiffer- 
ence. Prolapsions of the cord rarely take place after the mouth of 
the womb has become well dilated. The cord is probably down, in 
these cases, before the labor begins ; it is found protruding through 
an os uteri not larger than a half dollar. Such an os uteri is inac- 
cessible to the hand; therefore the accoucheur can by no means return 
the fallen cord into a cavity to which he cannot have access. He 
makes vain attempts to succeed by pushing the cord back within the 
constricted circle of the mouth of the womb, from which it again 
immediately escapes. If he could carry the cord quite above the 
head, it would stay there. It is evident, therefore, that with the 
hand alone, little success can be expected, in even the most patient 
endeavors to get the prolapsed organ in a place of safety. I have 
succeeded with my hand alone, but have much more often failed. 

Many various methods of repositing the cord, or putting it back 
into the womb, above the foetal head, have been proposed ; they have 
mostly been found ineffectual, the cord being apt to fall down again, 
even after it had been put into the proper place. I have never yet 
had an opportunity to try a method which I beg leave to propose to 
my readers, and which is as follows: Take a piece of riband or tape, 
a quarter of an inch wide and four or five inches long. Half an inch 
from the end, fold the tape back, and sew the edges so as to make a 
small pocket. Then fold the other end in the opposite direction, and 
sew that also, to make a pocket of it. Now if the cord be taken in 
the tape, and held as in a sling, a catheter may be pushed into one 
of the pockets, and that one thrust into the other, so that we shall 
have the cord held as in a sling, which is itself supported on the end 



414 PRETERNATURAL LABOR. 

of the catheter or womb-sound. Let the catheter be now pushed up 
into the womb, beyond the foetal head ; it will carry the secured 
portion of cord with it, and the catheter being withdrawn, the tape is 
left in the uterine cavity, where no harm can be occasioned by its 
presence. If required, several such tapes could be secured round the 
cord, and all of them fixed on the end of the same catheter, and pushed 
at the same moment far up within the cavity of the womb. 

Fainting. — Fainting or syncope, when often repeated in labor, is 
sometimes of so alarming a nature as to induce the practitioner to be 
willing to expedite the birth of the child, in order to put an end to so 
threatening a symptom. No prudent person, however, would be led 
to perform so serious an operation as Turning, or the application of 
the forceps, without being first fully convinced of its necessity. Of 
the degree and imminency of the danger here, none but a medical 
person can be supposed a competent judge, and the case must be 
left in his hands, strengthened, as he should be, by the counsels of a 
professional brother. I shall feel satisfied, therefore, to have merely 
referred to this cause and to leave it to the discretion of the attendant 
physician, without any additional remarks. 

Hernia. — A hernia, especially if of a kind liable to strangulation, 
might be a warrant for the accoucheur to hasten the moment of relief 
by the employment of the resources of art. We have also, in a few 
very rare instances, the dreadful accident of laceration of the womb or 
vagina to contend with. Of course, as soon as either of these acci- 
dents is known to exist, we should resolve to take the management 
of the delivery into our own hands, in order that we may, at least, 
save the infant, while we can also offer some faint chances of hope 
for the safety of the patient. 

Anemia. — Among the causes of preternatural labor, I ought not to 
omit a reference to a state of anaemia frequently met with in the pro- 
gress of pregnancy, and which, when it has attained a certain degree 
of intensity, is sometimes attended with circumstances of such grave 
consequence as to render the labor, when it does come on, thoroughly 
preternatural. The state of pregnancy is, as I have elsewhere re- 
marked, for certain women, not a purely physiological, but an emi- 
nently pathological one, and for the most part, the constitutional dis- 
turbances in them manifested, are chiefly referable to a state of the 
haematosic power. The woman who develops the uterus and its con- 



PRETERNATURAL LABOR. 415 

tents in gravidity, is not unfrequently found to be incapable of sup- 
plying the requisite quantity of blood for the ordinary wants of the 
constitution, and for the extraordinary demands of gestation. 

In some of the cases, so great is the destitution of the solid consti- 
tuent of the blood, which ought to amount to 210, while the watery 
part should be 790, that the solid portion is reduced perhaps as low 
as 100, or 150, while the watery element is increased in the same 
ratio. But, inasmuch as the blood is not only the pabulum of the 
body, but also its oxygeniferous medium, it is clear that in this state, 
there is not only a great debility from the failure of supply for the nutri- 
tive accretions, but a great derangement in the action of the nervous 
forces, for want of a thorough supply of oxygen. I am not more tho- 
roughly convinced of any principle in physiology than this, namely, 
that the stream of nerve force, conducted along the nervous fibrils to 
the distal points in the organs, is in a ratio with the changes produced 
in the neurine by the contact and combination, with oxygen. 

A perfect blood, viz., blood consisting of 210 solid constituents, 
and 790 water, is capable of taking out of the respired air in the 
lungs, the amount of oxygen required by the constitution of the indi- 
vidual, greater or less according to the exigencies of it under action 
or repose, whether physical or psychical. Such a blood can take 
from the atmosphere any quantity of oxygen required, since the blood, 
being perfect, is in a fit condition to take up a supply equal to the 
demand. Such blood is thoroughly and physiologically oxygeniferous ; 
but if the solid content of the blood be reduced one-half, and the 
aqueous element be increased proportionably, the blood, although still 
oxygeniferous, is far less oxygeniferous; and, though capable of taking 
oxygen out of the respired air in the lungs, is incapable of taking a 
supply equal to the demand. Therefore, when the nervous mass 
would send down its streams of biotic force to the distal points in the 
organs, those streams will be feeble, irregular and incompetent to the 
perfect manifestations which are required to constitute a healthful play 
of the said organs. This is the fact with regard to all highly anse- 
mical patients, whose debility is evinced not only in their diminished 
muscular energy, but also in the imperfectness and irregularity of 
their sensational, nutritive and secretory forces. The circulation, the 
respiration, and the innervation constitute a trinity of forces, mutually 
dependent, and incapable of existence the one without the other. But 
in anaemia, the respiration cannot do its office of breathing upon the 
blood, which, from its diluteness, cannot be perfectly oxygeniferous. 
Here is a failure, then, in one side of the triangle. But an imperfect 



416 PRETERNATURAL LABOR. 

blood gives an imperfect innervation. This is an attack upon another 
side of the triangle. An imperfect innervation implies incompetent 
power of the circulation. This is an attack upon the remaining side 
of the triangle, which is equivalent to saying, that in anaemia, the 
lungs, the brain and the heart are cast into a pathological condition, 
the prime element of mischief consisting in a diminished crasis of the 
blood, — for "the blood is the fluid body, and the body is the fixed 
and rigid blood." 

Now, a woman, whose lungs, heart and brain — which constitute, as 
it were, a triune centre of life — have become disordered by anaemia, 
goes through her pregnancy with difficulty and hazard, aggravated in 
proportion to the intensity of the disorders of those prime seats of her 
life forces. She, in an especial manner, becomes the early subject of 
those infiltrations of the cellular tissue that are denominated (Edema 
Gravidarum. A pregnant woman in this state, daily loses, or daily 
wastes, by its escape into the subcutaneous cellular tela, a great quan- 
tity of the serum of her blood, requiring for its reparation, a conse- 
quent effort of her hsematosic power which serves to exhaust the 
organs in which that haematosic force resides. Besides this, much 
diseased action results from the presence and pressure of the water of 
infiltration. 

Among the evils of the anaemical state, one chiefly to be dreaded 
in the pregnant woman is weakness or flabbiness of the muscular 
textures that, to a greater or less degree, invariably attends an aggra- 
vated anaemia. I do not allude to the weakness and flabbiness of the 
muscles of relation, nor even to those of digestion, for they might be- 
come so without seriously compromising the security of the patient. 
I allude rather to extreme relaxation and flabbiness of the muscles of 
the circulation. My clinical experience has presented to me a con- 
siderable number of examples in pregnant women, in whom the mus- 
cular structure of the heart had become so relaxed by anaemia as to 
permit the heart itself, in all its cavities, to be greatly augmented in 
volume, — to such a degree indeed as to allow its impulse to be per- 
ceived over large portions of the thorax. I feel well assured that 
many instances of this sort are misconceived of by the practitioners 
as being primary maladies of the heart itself. I have seen them so 
treated ; and have so treated them myself. But multiplied observa- 
tions have convinced me that the supposed diseases of the heart 
often prove to be merely anaemical relaxation of its muscular texture, 
which are perfectly recovered from when the anaemia wholly disap- 
pears. During the relaxed condition of the muscular substance of 



PRETERNATURAL LABOR. ANJEMIA. 417 

the heart, its walls yield to the lateral pressure of the blood forced 
into its cavities ; and its valves, having their edges too far separated 
by these dilatations, become incompetent for their offices. They no 
longer completely prevent the reflux of the blood, or its regurgitation 
against the current. Hence the loss of rhythm, hence the violent 
palpitations, hence the accumulation upon the pulmonic side, and 
hence the inability of the systemic side, to carry on the arterial injec- 
tions to the brain and to the whole constitution. Hence the violent 
oppression of the respiratory power, and the half asphyxiated condition 
of the patient whenever she happens to be called upon for extraordi- 
nary exertions of muscular force, or extraordinary exercise of percep- 
tive or intellectual power. 

The Student ought, in this representation of the state of the anaa- 
mical gravid patient, to perceive to what great risks she is exposed 
of serous effusions into her pericardium at least, if not into the pleuric 
cavities. She is prone to these effusions already in consequence 
of her anasarcous condition; and when, to the difficulties arising from 
a relaxed and dilated heart, a thin, watery and therefore imperfectly 
oxygeniferous blood, and all the sequelae thereupon depending, he 
supposes the presence of a quantity of serum within the chest, he will 
obtain a startling view of the dangers of the parturient ansemical pa- 
tient, and he will be ready to regard the labor which shall terminate 
such a pregnancy as a preternatural one, even should it not require 
his aid by the hand or by means of instruments. 

Case. — In 1841, I attended Mrs. S. R. during her first pregnancy. 
She was about twenty-two years of age — a short, but stoutly made 
woman. She was about six months gone with child when I was first 
called to see her, and was recommended to me by a medical friend, 
who declined to take charge of her case, supposing her to labor under 
disease of the heart, which rendered her situation extremely precarious. 
So great was the embarrassment of both the circulation and the respi- 
ration, that my esteemed friend had great cause to apprehend she 
might die in labor, from the exertions she should then be called upon 
to make. There was already great CEdema gravidarum; and slight 
muscular effort in moving about her apartment, served dangerously to 
augment the respiratory and circulatory embarrassment. I shall cite 
from my work on " Females" a notice of this case, which I am de- 
sirous to present to the reader of this volume. It may be found there, 
together with other observations on anaemia in pregnant women, at 
page 505. 
27 



418 PRETERNATURAL LABOR.— ANEMIA. 

" She presented all the appearances of great dilatation of both the 
auricles and ventricles of the heart — the impulse of which was per- 
ceptible to the right of the middle of the sternum. The pulse, except 
when she was in a state of recumbent rest, was large, gaseous, un- 
steady and very sudden. The face and whole surface were pale and 
flabby, the cornea nearly uncovered of the upper palpebra. The 
respiration was troubled, and on the least motion or emotion, precipi- 
tate and difficult. At the end of the seventh month, the lower limbs 
became considerably infiltrated, and the power of muscular motion 
much curtailed in consequence of its being always attended with 
violent beating of the heart, breathlessness, and uneasy sensations in 
the head, as pain, vertigo, noises and dimness of sight. 

"The progress of the pregnancy was accompanied with aggravation 
of all these appearances. 

" On different occasions she had attempted to walk in her house, 
and had fallen on the floor in a state of insensibility. I, being hur- 
riedly notified of such an accident, arrived on one of the occasions, at 
the house, soon after she was taken up from the floor and laid upon 
the bed. 

"I found her absolutely pale, scarcely able to speak, and completely 
blind when I arrived. She knew my voice, and opened her eyes to 
look at me as I spoke: — the eyes were bright, the pupils natural, but 
she was wholly without sight. She complained of some degree of 
fulness of the head. The pulse was still agitated. In a short time 
the sight returned and was perfect as before. 1 do not recollect how 
many times she actually fell in this manner, and with such following 
phenomena, but the accident was repeated several times. In nearing 
the term, the swelling of the limbs from oedema was greatly augmented, 
so as to affect the thighs, and the buttocks, and labia; the pericardium 
became also the seat of a dropsical effusion, so that a complete or- 
thopnea soon declared itself. 

" My patient could not lie down day nor night. If she sat up with 
a pillow against her back and shoulders, the oppression became so 
dreadful, she was obliged to throw them away; but, requiring some 
support, she placed her back against one of the posts at the foot of 
the bed : leaning on the slender cylindrical bed-post, she could find 
the needful support or rest without the oppression brought on by pil- 
lows or cushions. Here she sat day and night for many days, with 
very bad thin blood, which was imperfectly oxygenated, and so, 
greatly increased the disorders of the innervation. Her condition was 
truly deplorable, and it was difficult to imagine that the heart could 



PRETERNATURAL LABOR. ANAEMIA. 419 

ever recover its form, consistency and power, should she even escape 
death in the impending conflict of labor. In fine, labor came on, and 
in due time I delivered her with the forceps in order to save her from 
the necessity of exerting any voluntary force. " 

This young woman is now in the enjoyment of perfect health, hav- 
ing since given birth to several children, without any accident or 
extraordinary trouble whatever. Nor does she at present labor under 
any disease of the heart. 

Case. — Many years ago I had charge of the case of Mrs. F. B., 
who was at that time the mother of two children. She had been in 
delicate health since the birth of the last one, and came under my 
care during the last sickness of a medical friend, who had treated her 
many months as laboring under disease of the heart. To rise from 
her bed, and take a seat upon the sofa, was sufficient, on many occa- 
sions, to develop signs of approaching asphyxia by the disordered 
circulation consequent upon even the most moderate muscular exer- 
tion. I frequently observed the respiration and the heart's action to 
be so violently disturbed by these moderate efforts as to excite in my 
mind apprehension of her imminent death. The pulsations of her 
heart were discoverable far to the right of the sternum, as well as in 
the left side of her chest. She was deadly pale ; her lips swollen and 
blue ; and to lay the expanded palm upon her breast was to discover 
under it a quaking and a tremulous motion like that perceived upon 
pressing on a quagmire. After a long treatment her health amended 
somewhat. She conceived, and proceeded with doubt and difficulty 
to the term of her utero-gestation. I very confidently expected she 
should perish in her approaching labor, during the greater part of 
which she was obliged to be raised upon pillows on account of a 
distressing orthopnoea. As the labor drew very nigh its close, it 
was necessary for her to take a lower recumbent position for the 
greater convenience of her delivery. I expected constantly, during 
the progress of her labor, to find her convulsed, and in fact the crisis 
which was brought about by the last uterine contraction, and the 
final strong tenesmic effort of expulsion which brought her infant to 
the light, was instantly followed by a short but most frightful convul- 
sion, which, as it retired, left her apparently moribund. Somehow, — 
I know not how, — yet by the spontaneous powers of the constitution, 
she soon revived from this condition, and had no further serious 
trouble during her lying-in. In fine, this lady recovered a state of 
robust health. Her vast dilated heart, which seemed to me as large 



420 PRETERNATURAL LABOR. ANEMIA. 

as a quart measure, regained its normal generical magnitude and 
force, so that a few years afterwards, she ran before me as light as a 
girl to the fourth story of the Washington Hotel without drawing a 
long breath on reaching the top. Her heart, I feel perfectly assured, 
was sound and well again. 

This was a case of eenemia gravidarum, and the labor was preter- 
natural, for it was orthopnoeic, and it was followed by a terrific con- 
vulsion. With regard to the treatment of labors rendered preterna- 
tural, by aggravated degrees of anaemia, I have only this counsel to 
give to the Student : 1 . That he should clearly disclose to the friends 
of the patient, the whole extent of the perils by which she is sur- 
rounded, while he gives to herself the reasonable assurances of his 
hope to conduct her safely through the whole, course of her labor. 2. 
That in the Conduct of the case, he should take all possible precau- 
tions to avoid undue excitement of the nervous and vascular systems, 
forbidding the bystanders to exhort her to bear down, and frequently 
advising her to bear her pains patiently, waiting for their dilating 
effects, and so continuing until the presenting part, having come 
within reach of the hand or the forceps, may be gently drawn away 
almost without any spontaneous assistance of her own. If there can 
be found a case, in which the power of the forceps can be deemed 
more beneficent than in another case, it is that in which a parturient 
woman, with an immensely dilated heart, disparted valve, with cel- 
lular infiltration, and serous effusions within the chest, has barely 
power to live, but not enough both to live and expel the child from 
the womb. 

Perhaps it may not be inapposite in this place, to say that precau- 
tions should be taken, during the progress of the pregnancy, whereby 
to obviate these awful conditions of the pregnant woman at full term. 
It is true that the woman maybe greatly infiltrated in pregnancy with- 
out having a dilated heart, and such infiltrations readily disappear 
after the birth of the child; but they almost never disappear without 
leaving the patient pale and chlorotic — or, in other words, anaemical. 
I shall think that the woman excessively affected with oedema gravi- 
darum, should always be held to be threatened with relaxation or 
flabbiness of the muscular fibres of the heart, and the thereupon 
dependent disorders of which I have spoken. In order to overcome 
the oedema, it might in some cases be necessary, and no doubt is often 
effectual, to draw blood from the arm, to regulate the diet carefully, 
to entertain a soluble state of the bowels, and more than all these, to 
command the patient for a week or more than a fortnight even, to take 



PRETERNATURAL LAROR. EXHAUSTION. 421 

an unintermitted horizontal rest upon her bed or couch. To rest for 
a long time, and in doing so to avoid the dorsal decubitus as much 
as possible, is to put a stop to the progress of the infiltrating secre- 
tion, which I believe in true oedema gravidarum always begins and 
ends in the most dependent parts — to wit, the feet and legs. The 
circulation in such a posture, becomes more and more moderate, 
and the aqueous humor already effused, being now dispersed almost 
over the whole of the subcutaneous cellular tela, is imbibed by thou- 
sands of absorbing orifices, to whose action it could never be exposed 
while accumulated solely in the lower part of the trunk and in the 
inferior extremities. I confidently recommend this mode of treat- 
ment, and I assure the Student that I saw a young lady, a primipara, 
who in October, 1848, was five months past gone with child, in whom 
the oedema gravidarum had distended not the legs only, but very much 
also the pudenda; in whom the whole of the dropsical effusion dis- 
appeared in some ten days of a horizontal recumbency which she ob- 
served in consequence of my recommendation. These dropsical 
effusions should not be regarded by the Student as always the signs 
of an hydropic diathesis, but rather, as I have elsewhere explained, 
as the results of mechanical pressure and obstructions upon veins 
and absorbent trunks. Where the oedema has become very great, and 
the ansemical condition aggravated, there arises a real hydropic tend- 
ency or diathesis which leads to effusions into the belly or into the 
chest. 

Common experience and observation show very clearly the pro- 
priety there is, in all those cases where the anaemia has become 
thoroughly established or well set in, to prescribe for the patient the 
use of ferruginous tonics. It is scarcely necessary for me to repeat 
in this place, that the article most suitable for the occasion is the 
metallic iron of Mr. Quevenne. It may be given in doses of two 
grains in the form of a pill, to be taken immediately after meals three 
times a day. 

Exhaustion. — Labors are rendered preternatural by the occurrence 
of what is called Exhaustion. The causes of exhaustion are nume- 
rous. Any disproportion between the child to be born, and the straits 
or the excavation of the pelvis, might, by protracting the vain efforts 
of the woman, serve to exhaust her forces. This disproportion may 
be absolute or relative. The child may be preternaturally large, to 
that degree indeed as to make it impossible, or nearly impossible, for 
it to pass unreduced in magnitude through the parts of the female. 



422 PRETERNATURAL LABOR. — EXHAUSTION. 

Or the child may be of the normal size, while the pelvis is of under 
size, though in other respects well fashioned. Again, both the child 
and the pelvis may be duly proportioned to each other; yet the child 
may so present itself to the passages, as to retard or render impossi- 
ble its exclusion without extrinsical aid. Thus the child may pre- 
sent its head in extension at the superior strait, and descend in face 
presentation, with its chin to the sacrum and its forehead to the front 
of the pelvis; and it would prove a very extraordinary circumstance 
should the woman fail to fall into the state of Exhaustion, un- 
less delivered by the hands of the accoucheur : or there might be in 
the labor, a departure of the chin from the breast; or there might 
be such an occipito-posterior position of the head as to cause the two 
extremities of the occipito-frontal diameter to become immovably 
fixed upon opposite surfaces of the pelvis, constituting what is called 
arrest, and ultimately impaction, of the cranium of the foetus. An 
unturned or unevolved shoulder presentation, or a prolapsion of a 
hand or a foot along with the head ; or the impaction of the parts of 
two children at the same time in the pelvis, — might serve to exhaust 
the expulsive as well as the vital powers of the woman. In addition to 
the above causes of this kind of preternatural labor, we ought not to 
omit to mention rigidity of the vaginal cervix, whether simple rigidity, 
or whether rigidity arising from carcinoma, or the remains of uncured 
inflammation of the os uteri. In addition to these causes, the dynamic 
action of the womb may be contravened by a rheumatical state of 
the organ, or by the intrusion of a loop of intestine betwixt the 
front aspect of the womb and the contracting abdominal muscles, 
occasioning, during the labor throe, such great pain in the prolapsed 
loop of intestine, by compressing it between the hardened globe of 
the uterus and the contracting abdominal muscles, as to destroy the 
complacency of the constitution, and to overcome the proper conform- 
ableness of the innervations ad par turn. It is scarcely necessary for 
me to enumerate, in this connection, all the possible causes of exhaus- 
tion in labor; it is better that I should say to the Student that the 
parturient action of the uterus and accessory muscles, is effected at 
a certain expense of power developed in the nervous mass of the 
patient, and that while a woman in ordinary labor, and even in very 
severe and long protracted labor, is generally found to be capable of 
evolving from her nervous mass, and of sending down to the uterus 
and adjuvant muscles, an amount of innervative force sufficient to 
enable them to overcome all obstacles to the birth of the child, yet 
these obstacles are in some instances so rebellious, and so inexpugna- 



PRETERNATURAL LABOR. EXHAUSTION. 423 

ble, that the sources of the nerve streams become utterly exhausted, and 
the cerebro-spinal axis refuses any longer to repeat vain attempts to 
deliver, the woman lying motionless, feeble, and in a state which, to 
be truly denominated, should be called the commencement of the 
moribund state. 

Let the Student consider a little the condition of the parturient wo- 
man as above represented. He will see that she has long suffered 
the extreme of sensative distress or pain; that her heart and lungs 
and brain have co-operated in vain for the effectuation of her deliver- 
ance; that the lungs have breathed at a greatly increased rate upon 
the blood to charge it more abundantly with oxygen; that the heart's 
action has been enormously augmented in frequency and force, in 
order to hurry this oxygeniferous blood to the brain ; that the brain, 
combining with its oxygen, has evolved and sent down to the struggling 
organs and to the whole constitution, torrents of nervous force, so that 
not they only, but the whole constitution, have been actuated to the 
highest possible strain of their life-forces. Let the Student conceive 
that this force-production and this actuation under its stimulations, 
must come to a certain end, and that in doing so there will be found 
not disorders only, and feebleness and anaesthesia of the living solids 
of the body, but disastrous changes in the crasis, mixt, or constitution 
of the blood. And herein he will see a representation of the state 
of the woman lying in exhaustion after vain attempts to deliver herself 
in a protracted labor. The heart has lost its force and increased its 
frequency, for the sources of its innervation are greatly diminished, 
and its own physical structure has become changed in impression, 
ability and power. The respiration is hurried and short, for the 
diaphragm, the respiratory piston, makes short strokes frequently re- 
peated — for its power is nearly done. These states of the respiration 
and circulation necessarily involve disordered and diminished evolution 
of life-force in the nervous mass, and the blood, the fluid body, be- 
comes fatally changed. Let the Student take heed, therefore, of the 
beginnings of exhaustion, for she who has gone far into it is irreco- 
verably gone into it. It is exigent to deliver her, and that in the 
manner least likely to consume her feeble remains of life power. Ex- 
haustion is preternatural in labor, and even if it were not so, the duty 
becomes incumbent on him to render the labor preternatural by de- 
livering with the vectis, the forceps or the embryotomy forceps. Let 
him bring the chin to the front of the pelvis ; or let him use the vectis; 
or let him reduce its magnitude with the perforator, in order that the 
child may be born; or let him extract it with the forceps. Let him, 



424 PRETERNATURAL LABOR. EXHAUSTION. 

■where there is departure of the chin and consequent impaction, restore 
the chin to the breast, or convert it altogether into a face presentation ; 
let him convert the occipito-posterior into an occipito-anterior position ; 
let him return the prolapsed arm above the head ; let him put away 
the foot, and give space for the head to descend through the pelvis ; 
let him turn and deliver, or promote the spontaneous evolution of the 
fcetus ; let him disengage the prolapsed loop of intestine from betwixt 
the womb and abdominal muscles; let him reduce the size of the 
hydrencephalic head of the fcetus, in order that it may pass the straits; 
let him take away from the woman any further necessity to evolve 
biotic force for the expelling womb and abdomen ; let him take away 
from her agonized nervous mass all further occasion to perceive the 
irritation, the pressure, or the pain, and then, tenderly placing her 
upon her pillows, wait until perchance her blood may be redeemed 
from its perilous disorders, and her neurine again come to send down 
its streams of biotic power to all her organs and organisms, with a 
lessened, conformable and normal intensity. 

Signs of Exhaustion. — There is a great difference between ex- 
haustion and the mere cessation or suspension of labor pains. The 
woman may fall into labor, and after proceeding many hours towards 
the accomplishment of her delivery, she may stop for many hours to 
commence again, and again to cease, the work of expulsion. The 
act of labor being established, does not necessarily imply that the 
effort shall be continued until the completion of the process. A woman 
may be in labor during several hours daily for a whole month, dilating 
her os uteri to the size of a half dollar, and then closing it again so 
that it shall become as small as before the commencement of the 
process ; so a woman, even in advanced labor, may cease to labor for 
hours, or for many days, and yet suffer no perceptible illness. Such 
a case is not sickness. It is not exhaustion. Hence I warn the Stu- 
dent that he ought not to commit the serious mistake of concluding 
merely from the cessation of the pains, that the woman is in a state 
of exhaustion, or even beginning to fall into that dangerous state. I 
know not why it happens, as it often does happen, that labors begin 
and cease without any apparent indisposition ; but I know that the 
records of a man's practice should furnish him with many instances 
of the kind. 

To know the state of real exhaustion, let him look upon the con- 
dition of the vital triad — the brain, heart, and lungs; or, in other 
words, the innervative, the circulatory, and the oxygenating functions. 



PRETERNATURAL LABOR. EXHAUSTION. 425 

He will discover the condition of the brain by the psychical signs — 
illusions, hallucinations, delirium, altered temper; and by the physical 
signs, loss of co-ordinating power in the cerebellum, seeing power in 
the quadrigeminal tubercles ; the respiratory power in the state of the 
respiratory bulb ; by lessened intensity of the nervous force in general. 
The embarrassment of the circulation is discoverable by lessened 
power of systemic injection, and augmentation of the frequency of 
it — the oxygenation shows its failure by change of temperature, 
and of colorific power, all of which must be studied and profoundly 
studied and understood in the manifest action of the mind and the 
whole physical conduct and aspect of the patient. In a difficult labor 
tending to exhaustion, there will first be discoverable a most marked 
violence in the effort of the arterial pulse, which becomes voluminous, 
hard and frequent — beating about 110 pulses per minute. Whenever, 
after some time of protracted and fatiguing efforts with such a state 
of the pulse, the contractions of the heart are found to be repeated 
120 to 140 times a minute, the volume of the artery becoming re- 
duced, the temperature being also lessened, with a dry mouth and 
parching thirst, loss of courage and resolution on the part of the poor 
woman, the presenting part in the meantime making no progress 
whatever, exhaustion has begun, and has already proceeded even too 
far. 

Exhaustion is not likely to arise from the resistance of the soft 
tissues only. Even the most rigid cervix uteri gives way when the 
strength begins to go down. So also the most resisting perineum 
yields before the constitutional force is abolished or overthrown. Bat 
the impacted head, the unturned shoulder, or the impracticable pelvis, 
can never give way, and the efforts of the nervous, circulatory, and 
oxygenating forces must ever fail in presence of such inexpugnable 
resistance. In such instances the sources of the innervation must, 
sooner or later, become wholly exhausted, and the woman be lost. 

In the beginning of exhaustion, to deliver is to save the mother. A 
too long procrastination of her deliverance is most apt to insure her 
death. 

Exhaustion not being likely to ensue in consequence of soft resist- 
ance only, we have, even in the most obstinate cases of soft resistance, 
little to fear from contusion and a coincident irritation or shock; nor 
have we ground to look for dangerous sloughings at a later period. 
But when exhaustion arises from vain attempts to overcome the re- 
sistance of solid bone, we have, in addition to the direct effect of such 
efforts, in vitiating the blood and modifying the crasis of the nervous 



426 PRETERNATURAL LABOR. DESCENT OF BOWEL. 

mass, much mischievous impression upon the whole nervous system, 
radiating from parts engorged, contused or ruptured. 

Engagement of a loop of intestine in front of the womb. — 
The gravid uterus, at full term, lies behind the abdominal integuments 
and quite in front of the mass of intestinal convolutions and the 
transverse colon. It sometimes happens that a portion of the mesen- 
tery or mesocolon, I know not which, becomes so relaxed or elon- 
gated in the direction of its radius, as to permit a considerable por- 
tion of the intestinal tube to fall over the front aspect of the womb, 
and when once engaged there, to be driven down by the expulsive 
force of the belly, as low as, or even lower than, the umbilicus, 
where it is pinched, or compressed, or perhaps in a sense stran- 
gulated, by the contraction of the abdominal muscles in the labor 
throes. The Student will readily conclude that so distressed a con- 
dition of an important organ could not but introduce modifications 
in a labor. In such a case his attention will be drawn to the extreme 
suffering of his patient during her pains, which, instead of propelling 
the child rapidly, as might be expected in view of the intenseness of 
her distress, cause it not to advance even one tittle, while cries, jacti- 
tation, and the most disheartening expressions leave him at a loss to 
imagine the cause of delay, the more particularly when he finds not, 
in the position, the presentation, or the state of the soft parts, causes 
that might arrest the progress of the parturition. He ought to in- 
quire as to the existence of such possible causes. If he find them 
not by his vaginal exploration, let him ask questions as to the place 
and kind of pain, and he will discover that the woman has intestinal 
pain, and that that pain is situated between the womb and the integu- 
ment. Without making further special observations on this accident, it 
will suffice me here to say that, about four years since, I was in at- 
tendance upon a primipara lady occupying a high social rank in this 
city ; that the labor had proceeded without any untoward circumstance 
to an almost complete dilatation of the cervix uteri, when my patient 
began suddenly to complain most unaccountably of her pains. She 
became excessively agitated, and being a person possessed of great 
self-control, I was astonished and much alarmed by her moans and 
agitation. I could discover no just grounds of so great a distress in 
the condition of the presenting parts, or the textures within the pelvis ; 
but after careful inquiry, learned that the pain was in the uterine 
globe just above the umbilicus. She had not been affected with rheu- 
matismus uteri during her gestation or the antecedent part of her 



PRETERNATURAL LABOR. CARCINOMA. 427 

labor; I was obliged, therefore, to fall back upon the painful appre- 
hension that the texture of the uterus was about to give way at the 
seat of this pain, for that is what the practitioner ought to apprehend 
under such circumstances. Approaching the lady's bed-side, I re- 
quested permission to examine the abdomen by palpation, for which 
the nurse prepared her by uncovering her of all save the under gar- 
ment. Upon touching the belly, I found an irregular eminence in 
the place complained of. Gently percussing it, I discovered from 
its sonorousness that it was a considerable loop of intestine fallen 
down there, and which, being compressed between every uterine and 
abdominal contraction, had given rise to the agitation and pain. As 
the integuments were thin, I was enabled by a sort of taxis to push 
the loop upwards from its dangerous position, whereupon the labor 
pains became again normal, and the parturition thenceforth proceeded 
steadily and towardly to a happy conclusion. I have never met with 
a similar example. This was altogether an unnatural state for a wo- 
man in labor, and therefore I consider this woman's labor altogether 
a preternatural one. I thought it best to make this relation of the 
case, which, should such a one occur to an inexperienced practitioner, 
might cause him to regret that he had not been forearmed by thus 
being forewarned. I venture to remark, that the interruption to the 
progress of the parturient efforts here, ought to be assigned to the same 
category of influences as those already mentioned by me as depend- 
ing on the fall of a portion of intestine below the head in labor. 

Carcinoma Uteri.— Carcinomatous degeneration of the cervix and 
os uteri does not, unhappily, always obviate the power of fecundation 
and conception. A lip of the os tineas may be even far gone into 
carcinomatous degeneration without exciting suspicious discharges of 
mucus, sanies, or of blood, and even without developing such a de- 
gree of sensibility of the part as to preclude the consent of the female 
to cohabitation. The development of heterologue tissue in the cervix 
uteri is, in some instances, as slow and torpid as the development of 
similar tumors in the breast and other parts of the body. To become 
pregnant under such circumstances, is a great misfortune indeed, for 
gestation changes the whole life-activity of the uterus, which becomes 
greatly exaggerated in force and intensity, which is altered in form 
and density, and fatally tends, pari passu, to the augmentation of the 
heterologue life which has established itself upon the vaginal portion 
of the organ. Hence, the torpid and sleepy carcinoma takes upon it 
the more ferine life of the open cancer, and when the foetus, if ever, 



428 PRETERNATURAL LABOR. CARCINOMA. 

has attained its full growth, and the labor has begun, let the Student 
imagine the awful condition of the patient, one-half of the circum- 
ference of whose cervix uteri has become a mass of heterologue tissue, 
filled with the caudate cells, and the silvery bands of the cancerous 
malady, utterly unsusceptible of dilatation, almost frangible from its 
solidity, and exquisitely sore and painful. If such a womb should 
ever be opened, the dilatation of the mouth of it must be effected at 
the expense of the unaffected half of it, which is its only dilatable 
portion. If the circle of the os uteri must in labor become a circle 
of twelve or thirteen inches in circumference, in order to permit the 
escape of the head, what must be the unspeakable agony of the pa- 
tient, half the circumference of whose os uteri has become perfectly 
undilatable through carcinomatous degeneration. 

Case. — I saw, in the early part of the year 1847, a wretched human 
being, whose cervix uteri and vagina, the seat of a frightful ulcerated 
carcinoma, had just been torn to pieces by the escape of a full-sized 
foetus at term. 

Case.— On the 18th of March, 1848, I was called at 11 P.M. in 
consultation to a pregnant lady. She was thirty-three years of age. 
She has not had a child during the last fourteen years, having pre- 
viously given birth, I believe, to two children. 

Throughout the whole course of the present gestation, she has suf- 
fered with distressing, most distressing, nausea and vomiting. She 
is pale and emaciated. Has had frequent bloody vaginal discharges 
from the beginning of the pregnancy until now — expects her ac- 
couchement about the tenth proximo. 

At six P.M. she was attacked with flooding, since which time she 
has lost probably more than eight ounces of blood, which still con- 
tinues to ooze slowly away. They showed me a hard vaginal coa- 

gulum, larger than the whole thumb. 
lg " Figure 85 annexed, represents the size 

of the os uteri and the thickness of its 
edges: the posterior lip, which is much 
thicker than the remainder of the circle, 
is seen on the left side of the plan; this 
lip is prolonged into a tumor that bleeds 
at the slightest touch, and is evidently 
a mass of carcinomatous tissue in open 
ulceration. Figure 86, half size of nature, gives a correct notion 




PRETERNATURAL LABOR. CARCINOMA. 



429 



of the profile of this tumor, and of the degree of the aperture of the os 
uteri, in which the child's head is represented as pressing upon the 

Fig. 86. 




cervix and os. The tumor is seen in profile descending into the 
vagina. Figure 87 gives a front view of it. The tumor is hard 3 
wholly undilatable, so that the whole of the dilatation hitherto effect- 
ed, has been effected at the expense of three-fifths of the circle, the 
remaining heterologue two-fifths not having furnished anything to 
the dilatation, or if anything, an unconfutable proportion. 

Agreeably to the decision in consultation, she got an enema of 
forty-five drops of laudanum mixed in a fluidounce of clear-starch. 

March 19th, 12 M. She slept well after the enema, and has had 
no pain to-day. 

21st. Has continued well up to 3 P.M. to-day, when she was 
seized with the pains of labor, attended with inconsiderable hemor- 
rhage. I was again summoned to the consultation at 5J P.M. The 
os uteri was dilating. The tumor was now found nearer to the left 
ischium, as if the womb had been rolled upon its axis. As the pains 
increased, her distress became very great indeed, — I may say un- 
speakably great. The child had attained to within twenty days of 



430 



PRETERNATURAL LABOR. — CARCINOMA. 



term, and it was apparent that full two-fifths and more of the cone of 
the cervix uteri could not furnish any material for the necessary dilata- 
tion. Hence there must be the greatest danger of rupturing the tissue, 
and accordingly, at six o'clock in the afternoon, the whole projecting 
mass of the tumor came away into the hands of the gentleman in 
attendance, who handed it to me, and of which a good representation 
is given in Figure 87. 

Fig. S7. 




The lady was a person of admirable temper and manners, but the 
greatest courage and the utmost stretch of her Christian fortitude and 
patience could not conceal from the anxious spectators the extremity 
of her agony. 

There was no great increase of hemorrhage after the separation and 
escape of the tumor, but the bag of waters was thrust down far out- 
side of the ostium vaginae, soon after which, at 6| P. M., the child 
was expelled. A solution of morphia was administered to her, and she 
became composed. At one o'clock in the morning, she was seized 
with a rigor, which soon became a violent ague, which lasted more 
than one hour, whereupon febrile reaction ensued, with a pulse at 



PRETERNATURAL LABOR. VARIOLA. 431 

180 beats per minute. This febrile condition was attended with 
violent pain, and intense sensibility of the abdomen to pressure. 
There had been very little discharge since the expulsion of the child, 
and the mass of the uterus was well and firmly contracted. Upon 
the establishment of the febrile reaction, she was bled to the amount 
of twenty-two ounces with great relief to her distress, and without the 
least appearance of syncope. 

Wednesday, March 22d. At one o'clock to-day she suddenly began 
to sink. She was in the full possession of her intellectual powers, 
and had not the slightest pain. She died in the afternoon. Upon 
examining the body, about twenty-four hours after death, there was 
no trace of hemorrhage in the belly, nor any marks of peritonitis. 
These figures were drawn by Mr. Gihon, from the preparation now 
preserved in my collection. 

Small-Pox. — There can scarcely be a more disturbing cause of a 
parturition than small-pox existing in the system of a woman in la- 
bor; not because it modifies the presentation or position of the child, 
nor because it dangerously interferes with the action of those dynami- 
cal forces by which the product of the conception is discharged from 
the womb. A labor, or, to speak more definitely, a perfectly normal 
parturient act, in itself not necessarily dangerous, nor fatal, may have 
a mortal result, for, the woman who has been confined cannot be said 
to have completed the act of childbirth, as relative to herself at least, 
until she shall have recovered a healthful non-gravid condition. I 
think it is right, therefore, to regard as a preternatural labor any one 
which from some complication, whether of disease or accident, ex- 
poses the mother after delivery to the most imminent danger of death. 

I will not say that every woman who gives birth to a child while 
laboring under small-pox must inevitably perish, since my clinical 
experience has shown me that the contrary may, rarely, be the case. 
But I do hold to the opinion, that a pregnant woman, laboring under a 
considerable attack of small-pox, is far more likely to be lost than 
saved, whether she miscarries, whether she be prematurely confined, 
or whether she give birth to her child at the full term of utero-gesta- 
tion. A pregnant woman may be attacked with small-pox even in 
its most direful confluent form, and yet recover well, provided labor 
does not come on in the course of the disease; but, if she be confined 
or suffer abortion, she shall hardly escape death by hemorrhage from 
the womb, or by metro-phlebitis coming on early after the detachment 
and expulsion of the placenta. 



432 PRETERNATURAL LABOR. — VARIOLA. 

A late author on obstetrics has expressed the opinion that the 
bleeding orifices upon the inner aspect of the womb — those, to wit, 
which give issue to the lochia — cannot be restored to a non-gravid 
health save by the intervention of an adhesive inflammation of those 
vessels. That adhesive inflammation is phlebitis. And he further 
expresses the opinion that the milk-fever of women, and the same 
milk-fever which is known to affect our domestic quadrupeds after 
their parturition, is the constitutional disorder developed by the purely 
topical and limited phlebitis affecting the uterine orifices above men- 
tioned. This opinion appears to me to be worthy of respect, upon a 
simple annunciation of it, as well as from the confidence to be reposed 
in the judgment of the author in question. 

If, now, the Student will consider for a moment the nature of that 
direful malady of which we are speaking, and reflect upon its unques- 
tioned power to modify the crasis of the blood, he will feel no surprise 
to observe, as he will in future have melancholy opportunities to do, 
the tendency of the variolous poison either to set on foot, or to aggra- 
vate any necessary anormal phlebitic affection to which the parturient 
female is liable; nor will he feel any greater degree of surprise to 
find that the modified blood of the variolous patient continues to ooze 
from the parietes even of a well contracted uterus after delivery, and 
that his haemostatic agents are all alike futile in opposition to the tend- 
ency of the vessels to allow of protracted and ultimately fatal losses 
of the vital fluid. 

My principal design in introducing this section here is, in the first 
place, to point out the great necessity there is for pregnant women to 
avoid the contagion of variola; for I think I am quite correct in stating 
that the sentiment of the profession is almost unanimous, that the 
woman who is confined during small-pox, dies. This is the general 
rule. The exceptions are here and there a few cases, in which she 
escapes as by miracle. I must take the liberty to reiterate my opinion 
that she dies either from the ooze, or from phlebitis, which is essen- 
tially endangitis. I could have no design, in this place, to set forth 
any precepts in regard to the Conduct of labor, in a woman suffering 
under small-pox. I have already said that that malady is not to be 
supposed to modify either the presentation, the position, or the dy- 
namics of any labor. 

Now let the Student beware not to expose his gravid patient to the 
least danger of variolous infection ; and, therefore, let him never dare, 
under any circumstances, to vaccinate a pregnant woman, or one 
recently confined. To give this precept is the essential motive I had 



PRETERNATURAL LABOR. VACCINATION. 433 

for introducing this article into my work, and I am the more desirous 
to attract the attention of the Student to this point, because I know 
that the brethren in general are not in the least suspicious, that to 
vaccinate a pregnant woman is to expose her to great hazard. I re- 
iterate the assertion that the virus of small-pox is eminently inimical 
to the life of the pregnant female, and I aver that the virus of the 
vaccine inoculation is little less so than unmitigated small-pox. 

If the Student will take two clean lancets, and plunge the points 
of them into a mature small-pox pustule, he may send one of them a 
hundred leagues eastward, and with it inoculate an unprotected indi- 
vidual, who will receive from it the infection of unmodified variola; 
and consecutive inoculation from this line would repeat variola for 
centuries. Let him send the other lancet a hundred leagues west- 
ward, and with it inoculate the udder of a healthy cow. He will in 
this way communicate to the animal a vaccine infection, from which 
vaccine inoculations of human beings may be consecutively repeated, 
for centuries. So that the variolous pustule in the human being has 
communicated the vaccine infection to the cow, which vaccine infec- 
tion may likewise be repeated, without modifying it further, through an 
unknown series of human bodies. The generical force of the inferior 
animal has modified a poison produced by the generical force of the 
human being. It has changed it, not destroyed it. It retains a portion 
of its variolous power inimical to the pregnant woman, and to expose 
such an one to its rage is a gross imprudence and misapprehension 
which I hope no Student reading this book will ever be guilty of. The 
shocking spectacles of distress that I have witnessed, from the vacci- 
nation of pregnant females, have so impressed my mind w r ith the 
enormity of the imprudence, that nothing, I think, could tempt me to 
commit it myself. The most furious adenitis, which is endangitis, 
and which, in other words, is pyogenic fever, is one of the conse- 
quences likely to result from every true or spurious vaccination of a 
pregnant female. I am firmly convinced that it is far better for the 
physician, during the epidemic of small-pox, to leave his pregnant 
patient to the chance of a natural infection, than certainly to bring 
her within the scope of its virulent power by a vaccine inoculation, 
which is but a variolous inoculation modified by the generical force 
of an inferior zoological genus. 

If I venture to put forth such opinions as the above, it is hardly 

incumbent upon me further to protest against the temerity of those 

who, during the existence of a small-pox epidemic, recommend, and 

even proffer, what is called re vaccination, to those who, having 

28 



434 PRETERNATURAL LABOR. TWINS. 

been already vaccinated, might be held to be protected; I mean to 
pregnant women. I have seen pregnant women, very nigh to term, 
unnecessarily revaccinated, with consequences so terrific that I think 
I would not, for a thousand golden crowns, vaccinate any woman, 
knowing her to be pregnant. 

Twins and Triplets. — In Churchill's System of Midwifery, Phila. 
ed. 1846, p. 411, there are statistical statements on the subject of 
twin and triplet pregnancies. Dr. Churchill states that out of 448,998 
cases of pregnancy we have 5,776 cases of twins, or one in 77f , and 
77 cases of triplets, or one in 5,831 cases. A case that occurs only 
once in 77 labors, and in the course of some men's practice not so fre- 
quently, will be esteemed to be preternatural, for that is natural which 
occurs constantly, that is more nearly natural which occurs frequently, 
and that is preternatural which occurs very rarely. A triplet labor, 
which, according to Dr. Churchill, occurs only once in 5,831 cases, 
will certainly be admitted to be an unnatural labor, or, to use a tech- 
nical phrase, a preternatural labor. I shall not err then in setting 
down twin and triplet cases as cases of preternatural labor; at least 
I find it more convenient to arrange them here than to give a separate 
chapter on the subject. 

As a general rule, a twin labor is not suspected to be so until after 
the birth of the first child, for a woman carrying twins in the womb 
is found frequently not to be larger than she who carries but a single 
one. Two children of six pounds weight each, do not weigh so much 
as a single child of twelve pounds and a half, and the liquor amnii 
of the double pregnancy may be far less in quantity than the liquor 
amnii of a uniparous womb. If a woman in the latter weeks of her 
pregnancy should become very lusty, as it is called, or if the abdo- 
minal walls, becoming weakened, allow the uterus to fall far forward, 
so as to make the belly a little pendulous, that circumstance may 
give rise to misapprehension, and the woman is apt to fear that she 
will be so unfortunate as to give birth to twins. In practice the 
Student will find that ten women shall fear twin labor, for one that 
shall really suffer it ; and that in ten twin labors, there shall be only 
three or four in which twins shall be suspected to exist. It is not 
difficult in the pregnancy to ascertain the existence of twins, since the 
use of the stethoscope serves to reveal the pulsations of two distinct 
hearts, and, moreover, during the flaccid states of a womb, if a woman 
lie upon the back, the feet drawn up, it is not difficult by external 



PRETERNATURAL LABOR. TWINS. 435 

palpation to detect the existence of two distinct, orbicular, hard 
heads. 

Although I prefer to speak of twin and triplet labors in the chapter 
upon preternatural labors, I am ready to admit that many women 
giving birth to twins, find themselves delivered promptly and with 
little pain, especially when the children, as is usually the case, are 
under size; nevertheless, in twin labors with large children — and I 
have seen two children the sum of whose weights was sixteen pounds 
and a half, and where the ova contained a very extraordinary amount 
of liquor amnii — the process of parturition is exceedingly slow, dis- 
heartening and painful; the overloaded uterus acts feebly and irregu- 
larly, labor is long in establishing itself, the excessive extension of 
the muscular tissue of the uterus prevents the organ from propelling 
the point of the ovum into the cervix and through the orifice of the 
os ; the bag of waters is therefore slow in being formed. 

It rarely happens that the waters of both the ova come off together. 
If the amniotic sac which contains the first child or the presenting 
child should have discharged its fluid contents, then the expulsive 
power of the uterus must be communicated to the advancing child by 
means of the unbroken ovum of the second birth; such an elastic 
and compressible medium for the communication of the expulsive 
force, must frequently have the effect of decomposing and rendering 
futile the exertion of it. If the membranes of the first child remain 
whole, and those of the second child be first broken and discharged, 
as sometimes happens, the same effect is produced. I have seen a 
labor in which the first child pushed the placenta of its brother before 
it into the world. In case both ova are ruptured, the lowermost child 
must be thrust down by the uppermost child; but, as the uppermost 
child is never directly above the lowermost, its force must be com- 
municated laterally. It acts obliquely upon the body of its mate; and 
the practitioner who finds an os uteri ductile and non-reluctant, is 
ordinarily embarrassed to make up his opinion as to the cause of the 
slowness of a labor, whose slowness seems inexplicable, since where 
the resistance is small and the woman in good health, he expects the 
advance to take place at a certain usual rate. He might be tempted 
on this account to exhibit some ergot, or administer some stimulants, 
or exhibit some provocative to increased uterine action. He ought to 
do no such thing; the duty of an accoucheur is to inquire into the 
cause of the slowness. Let him rise from his seat and apply his ear to 
the abdomen of the woman; if he finds the foetal heart, let him ascer- 
tain its place, as relative to the top of the symphysis pubis, nearer or 



436 



PRETERNATURAL LABOR. TWINS. 



Fig. 88. 



more remote from it in the hypogastrium ; and knowing where the head 
is, then with his hand upon the abdominal uterine tumor, he will at 
once come to the conclusion that the womb contains one child, or more 
than one child. In the latter case, let him find the heart of the second 
child, and the position of that heart will afford him a tolerably good 
diagnostic as to the presentation of the second twin, as offering either 
a cephalic or a pelvic presentation. If the accoucheur then finds that 
the uterus is overloaded, and that it is acting at a great disadvantage 
in consequence of its being compelled to communicate its expulsive 
force through the body of the first child obliquely to that of the ad- 
vancing twin, he will understand his case, and act accordingly. 
In twin labors the children present both by the head, or one by the 

head and the other by the breech, as 
in Figure 88. 

In case the children present both 
by the head, there is risk that when 
the first head shall have fairly sunk 
below the plane of the superior strait, 
the other head may, by the expulsive 
action of the womb, be thrust down- 
wards into the superior strait against 
the throat of the first child, which it 
crushes against the opposing wall of 
the pelvis, and thus locks the lower 
head, which cannot descend because 
the thorax to which it is attached can- 
not enter the brim, on account of the 
presence there of the second head. 
Let the Student imagine the difficulty of treating such a case, for the 
first head fills the cavity in such a way as to prevent his passing his 
hand up, and he w T ell knows that when the foetal head is fairly within 
the excavation, it is an extraordinarily difficult, and often impossible 
thing to thrust it again above the superior strait, in order to turn and 
deliver. I am happy to say that my clinical experience has never 
furnished me with an example of this sort; a case of the kind occur- 
red to one of my brethren here a few years since, which embarrassed 
him greatly; he could neither return the first head nor displace the 
second; he took the measure, therefore, of decapitating the lowermost 
child, and, after its head was removed, the second child was delivered, 
and the headless trunk of the first one followed it. 

In case the first child should present by the breech and descend 




PRETERNATURAL LAROR. TWINS. 437 

through the pelvis, there is always great reason to fear that the second 
child, presenting by the head, might have its head urged down faster 
than the head of the breechling; if it should be jammed into the 
pelvis before the other head can get possession of it, it would present 
another example of the process in which one head is keyed by another. 
There is less danger in this case than in the former, because the trunk 
of the child would not form an insuperable obstacle to the passage 
of a hand, whereby to displace the keying head. 

It has happened to me, on different occasions, to find the woman 
becoming so much fatigued, so much worn out, indeed, by the pro- 
tracted efforts of a twin labor, that I felt obliged at the last to give 
the assistance of my forceps, both for the first and second child. 

A labor with twins is one in which there may be either one or two 
placentae; it sometimes happens that both the children are contained 
in a single chorion, but each child must have its own amnion ; if 
there are two chorions, there will be two placentas, and these placentae 
will be situated in different and opposite parts of the uterus. A labor 
in which there are two separate placentae, and in which the first pla- 
centa is detached and discharged with the child, is one in which the 
placental superficies is likely to bleed, for there cannot be perfect 
condensation of the placental superficies of such a womb. A twin 
labor in which there is a single chorion and a single amnion, is one 
which could scarcely fail to give birth to a specimen in terratology, 
for there is nothing that prevents the fusion of the parts of the twins 
in the same amniotic sac: whereas such fusion of parts is impossible 
in two separate amnia. Chang and Eng must have existed in a single 
amnion: so did Reta Christina. The same must have been the case 
with Dr. Pfeiffer's double headed infant, to which I refer the Student, 
and with my specimen of the omphalodyne, contained in the museum 
of Jefferson Medical College. 

One never has charge of a twin labor without feeling some anxiety 
with regard to the hemorrhage likely to follow the birth of the first 
child, and the accoucheur should not dare to leave the woman until 
she be safely delivered of the second. As a general rule, the same 
contractility of the uterus which expels the first child, after a slight 
pause, resumes its operation for the expulsion of the second, just as 
happens as to the expulsion of the after-birth in a uniparous labor: 
and we may therefore expect that within the hour the presenting part 
of the second child shall descend through the os uteri into the vagina. 
I think I have never waited so long as an hour. When the membranes 
have already been ruptured, I have found the child to descend earlier 



438 PRETERNATURAL LABOR. TWINS. 

than that, and when they had not already given way, I have ruptured 
the oYum within twenty minutes. As my own experience in this 
particular has been fortunate, I venture, upon that ground, to advise 
the medical Student to follow the same course. Some persons prefer 
to wait for a longer time, and I admit, if the patient be carefully ob- 
served, if there be no signs of hemorrhage or faintness or other exi- 
gent motive for interfering, he might feel himself justified in waiting 
for a longer time than that I have indicated. Let him always make 
the diagnosis as to the presentation before he proceeds to rupture the 
ovum, and should he find a cross birth, a possible event, let him hasten 
to pass his hand high up on the side of the ovum, penetrate it there, 
and seize the feet in order to turn and deliver. 

In these cases there ought to be a good light on the patient's face, 
for the hemorrhage is sometimes astounding, and the earliest indica- 
tions of it may, on certain occasions, be detected in the expression 
and tint of the countenance. Whenever hemorrhage is suspected to 
have begun, or is known to have commenced, there should be no 
hesitation in rupturing the membranes ; the discharge of the second 
sac fulfils Louise Bourgeoise's commandment, to let the water off in 
order that the womb may condense itself. The accoucheur, under such 
circumstances, would act according to the indication ; if the hemor- 
rhage is sudden and startling, he would turn and deliver, provided 
the head is above the superior strait ; he would seize and extract it 
with the forceps, provided it were in the excavation. 

As soon as the second child is born, pressure should be made upon 
the hypogastrium to promote a tonic contraction of the uterus ; the 
lately over-distended, but now relaxed, belly, should be sustained by 
a proper binder and compress, and the placenta or placentas should 
be carefully extracted. 

In triplet labors the same causes of slowness in effecting the earlier 
operations of parturition exist, as in the twin case ; the expulsive 
power is even more decomposed, since it is communicated through 
three bodies ; there is the benefit in general, however, that triplets are 
smaller than twins, and the distension of the cervix uteri, the vagina, 
and the external organs, is not so great as in uniparous or twin labors, 
in consequence of which, the last pains are less distressing. I saw 
a lady in labor, in this city, however, who gave birth to triplets, the 
sum of whose weights was twenty-one pounds and a half; they were 
fine children ; the mother had nearly lost her life from an exhausting 
hemorrhage, which followed the birth of the last child. The super- 
ficies of the placenta, required for the aeration and support of three 



CONDUCT OF PRETERNATURAL LAROR. 



439 



such children, must have been very vast, and a most powerful con- 
traction of the uterine globe would be required to constringe the 
uterine orifices after such a labor. 

I have never seen a case in which four children were delivered at 
one birth. 



Fig. 89. 



Management of Preternatural Labors. — Preternatural labors 
may be terminated with the hand alone, or b}- means of instruments. 
The simplest of midwifery instruments is the fillet, which consists of 
a riband of silk or linen. 

The fillet is chiefly employed as a means of drawing down the 
buttock, in cases of breech labor, where the pains are incapable, with- 
out assistance, of completing the delivery. A very good fillet may be 
made of a strip of linen some three inches wide and twenty-eight or 
thirty inches in length. It is not always a very easy matter to apply 
it — and there is great difficulty to get it adjusted in all cases, except 
when the breeeh is quite low in the excavation and completely out of 
the circle of the os uteri. Previously to making any attempt to use 
it, it should be prepared by drawing it through the hand, filled with 
a good quantity of lard — or else it may be soaked in thick flaxseed tea, 
or in white of eggs. Without this precaution it will not pass over the 
thigh of the child, or it will rub the sur- 
faces so as to endanger their excoria- 
tion. 

In order to make use of the fillet, let 
it be passed over the thigh that is 
nearest to the pubis. Roll up four or 
five inches of one of the ends of the 
riband into a roller, which may be 
passed into the vagina, and pushed 
with one or two fingers between the 
belly of the child and the front of the 
thigh which is in contact with the belly. 
The point of the finger will carry the 
little ball or roller across the groin 
either inw^ards or outwards, as the case 
may be, and w r hen it has got free from 
the pressure of the surfaces of contact, 
the roller or ball at the end may be 
brought out at the ostium vaginae, and 
the remaining portion passed upwards, 
so as to get the fillet arranged to allow the two free ends to be tied. 




440 CONDUCT OF PRETERNATURAL LABOR. 

The drawing, Fig. 89, shows the appearance of the fillet, when 
rightly placed, and the mode of operating with it. 

The efficacy of its action would be greatly enhanced by placing 
it upon the groin that is farthest from the pubal arch — but that is 
a feat of dexterity that can rarely be performed. 

In drawing downwards, one should act only during a pain, or 
coincidently with a tenesmic effort of the patient, and it should 
never be forgotten, that the neck of the thigh bone is a very fran- 
gible thing in the unborn foetus. This caution is necessary, in order 
to prevent a fracture or dislocation of the hip-joint. The mere re- 
membrance that such an accident might happen would prevent any 
prudent person from exerting an undue force with the fillet. 

Notwithstanding the reasonable dread of doing mischief by violent 
and untimely tractions — it is true that very great assistance may be 
given to the woman in labor by this simple implement. 

The fillet is also applied, on some occasions, to the wrist in pro- 
lapsion of the hand, in order, by means of it, to keep the hand down 
at the side, when we turn to deliver in shoulder cases. I have never 
found it necessary to take any such precaution ; as I have always 
thought that I could bring down the arm, in case it should be lifted 
along side of the head, and I have not chosen to embarrass myself 
with the string. 

The fillet is also by some writers recommended as a means of 
securing one foot that has been brought out at the vulva in turning, 
w T hile the hand is passed upwards again to seek for the other foot. I 
do not think it necessary. Indeed, when I have got one foot down, I 
care not much to bring down the other. If it be left in the womb, we 
have rather an advantage by it ; since, in such a delivery, we have 
the benefit of both the footling and breech labor. 

Turning. — The Student has learned that the most natural labor, 
one in which the vertex presents, in the first position, may suddenly 
become a preternatural one in consequence of the coming on of 
hemorrhage, a series of bad fainting fits, convulsions, &c. &c, and 
which establish the indication to proceed at once to the delivery. 

Fig. 90 serves very clearly to express the situation of the child 
presenting in the first position of the vertex. It may be that this 
child's head had in a good measure occupied the circle of the os 
uteri before the accident occurred which established the indication 
to deliver by turning. If the head had wholly escaped from the 
circle, the indication to deliver by turning must have been considered 



CONDUCT OF PRETERNATURAL LABOR. 



441 



Fig. 90. 



wholly set aside in favor of a forceps operation; for in general, when 
the head has once escaped from the os into the vagina, it cannot be 
thrust into the womb again, for the 
cervix uteri will by that time have 
contracted pretty strongly around the 
neck of the infant. Hence the rule 
of practice is to turn and deliver if 
the head be still in the womb ; but if 
it be in the vagina, we are to extract 
it by means of the forceps. In fact, 
if it be wholly in the vagina, it is 
below the superior strait ; but to at- 
tempt to return the head through the 
superior strait and through a con- 
tracted os uteri also, is a thing too 
preposterous to be thought of. 

The drawing above mentioned, 
Fig. 90, will show to the Student 

what he will have to do if he makes up his mind to turn. It will 
show him, namely, that he will be obliged to thrust the head out of 
the plane of the superior strait, which it occupies, in order to let his 
hand pass upwards in exploration; he will see by inspecting the figure 




Fig. 91. 



Fig. 92. 





that he must seek for the feet in the right and posterior portion of the 
upper part of the womb ; he must push the head, therefore, upwards 
and to the left, and not upwards and to the right, and he must grasp 



442 



CONDUCT OF PRETERNATURAL LABOR. 



the feet with the palmar and not with the dorsal surface of the hand. 
Which hand shall he use ? Let him look at the figure, and he will see 
that in this labor he must use the left hand, and carrying that hand 
upwards according to the directions given in my article on Turning 
at page 366, he will find the feet one or both as in the figure, and 
grasping them firmly with the thumb and fingers, he will draw them 
downwards towards the os uteri, assisting his left hand by means of 
the right one pressed upon the fundus of the womb upon the outside. 
In this way, drawing the feet downwards, he keeps the head above 
the plane of the superior strait by means of his wrist and palm, a 
precaution he must by no means overlook, lest the head, urged down- 
wards by the force of the contractions, should become engaged in the 
pelvis together with the foot, as seems about to happen in the drawing 
annexed, Fig. 92. If, through forgetfulness of duty or the want of 
a proper dexterity, he should permit this accident to happen, he would 
procure for himself superabounding vexations, for his patient a great 
increase of pain and hazard, and for the child an almost certain death. 
Let him never forget, therefore, while drawing down the foot, that he 
must keep the head up if possible. 

After drawing the feet through the ostium vaginae, and w 7 hen the 



Fiff. 93. 



Fig. 94. 





turning is completed, which he will know by an exploration with the 
right hand of the form of the abdomen, and by perceiving that the 



CONDUCT OF PRETERNATURAL LABOR. 



443 



Fig. 95. 



hips of the child are now engaging in the excavation of the pelvis, 
he should, if he draws at all by the limbs, make his chief effort of 
traction by means of the right leg of the child, as in Fig. 93. By 
acting in this way he will cause the child's face to turn towards the 
left sacro-iliac junction. Before the turning, it looked towards the 
right sacro-iliac junction. Let him look again at Fig. 93, in order 
to see how he would make the face of the child come to the front of 
the pelvis if he should incautiously make his tractions upon the left 
foot only. 

When he has extracted the child as far as the navel, let him do 
what is represented in Fig. 94, that is to say, let him carefully draw 
down a considerable loop of the umbilical cord, setting that organ at 
liberty, so that no danger may be incurred of breaking it or tearing 
it out by its roots at the umbilical ring. 

The patient should certainly be now turned upon her back, and the 
child's legs should be wrapped in a napkin in order to hold them 
firmly. As soon as a good part of the 
thorax is expelled, let him pass two fin- 
gers upwards to the top of the shoulder 
that is most conveniently within his 
reach, raising the body of the child up- 
wards towards the pubis if he desires 
to get at the posterior shoulder, or de- 
pressing it towards the sacrum if he 
wishes to act on the anterior shoulder. 
Sliding his fingers from the acromion as 
far as he can towards the bend of the 
elbow, let him force the elbow down- 
wards, causing it to sweep along the 
breast of the child. As soon as the 
elbow is withdrawn, the hand will come 
forth and the shoulder be extricated, 
after which let him proceed in like man- 
ner with the remaining shoulder, using the fingers of the other hand, 
as in Fig. 95. 

Both shoulders being delivered, let the Student next raise the trunk 
of the child upwards towards the mother's abdomen, a precept which 
has been forgotten in the annexed design, Fig. 96. It is extremely 
important not to forget this rule of practice. What the Student wants 
at this point, is, a great degree of flexion of the head ; let him carry 
the breast away from the chin by turning the child's trunk upwards 




444 



CONDUCT OF PRETERNATURAL LABOR. 



Fig. 96. 




towards the mother's abdomen, as above directed, and then intro- 
ducing one or two ringers as far as the child's mouth, let him pull the 
chin downwards towards the uplifted breast of the child — thus re- 
storing the chin to the breast. As a 
general rule, this manoeuvre will effect 
the flexion that is to be desired ; — not 
always so, however, for the mouth some- 
times may be opened very wide, and 
the upper maxilla will not descend to 
close upon the lower. Let the Student, 
in this case, push the vertex upwards 
by means of two fingers inserted behind 
the symphysis, and then with a finger 
on each side of the nose, let him pull 
the superior maxilla downwards, to 
make it shut the mouth. The occipito- 
mental diameter, see-sawed in this 
manner, will be made to coincide with 
the axis of the inferior strait, whereupon 
pulling by the shoulders with one hand, and with a finger in the 
mouth with the other, the head may be withdrawn in a direction 
coinciding with the curve of Professor Carus. 

Should the resistance to the escape of the head be too considerable, 
and the child's life be placed in danger from the delay, two fingers 
of the left hand should be passed into the vagina as high as the malar 
bones, one on each side of the nose. The fingers being now some- 
what flexed, will thrust the posterior wall of the vagina away from the 
mouth and nostrils, giving free access of the atmospheric air to those 
orifices; the child will immediately begin to cry, though unborn, giv- 
ing time for the patient to rest, and for the accoucheur to consider of 
his duty. I have heard this vagitis vaginalis for many minutes, and, 
indeed, have in this manner enabled the child to continue breathing 
until my forceps could be brought, from a considerable distance, 
wherewith to deliver the head. As to the manner of applying the 
forceps in this case, I refer the Student to the chapter describing the 
uses of that instrument. 

The Student ought very carefully, yet very promptly, to decide 
upon the line of duty under the sometimes very sudden emergencies 
of this sort of labor ; to set the matter before him in a clearer light, 
let me reiterate the precept, to turn and deliver if the head be not in 
the vagina, and to deliver by the forceps if it is wholly expelled from 



CONDUCT OF PRETERNATURAL LABOR. 445 

the mouth of the womb. If he should make a mistake as to the point 
of duty, he might inflict a serious injury upon his patient, by passing 
the blades of his instrument within the contracting bands of the 
cervix uteri ; or, on the other hand, he might allow her to bleed to 
death from hemorrhage, while expecting the return of the messenger 
sent to bring his forceps from the distance of half a mile. 

I was sent for to assist a gentleman waiting upon a woman in labor. 
I arrived at the spot in a very few minutes, and found both the child 
and the mother dead upon the bed; my friend, the accoucheur, told 
me that he had been sent for with an urgent request to hasten to the 
house, but being absent from his office, a considerable delay occurred ; 
when he came to the bedside, he found the woman flooding danger- 
ously, and much exhausted by the loss. Perceiving the exigency of 
her circumstances, he despatched a messenger in haste to bring his 
forceps, from a distance of more than half a mile ; in the meantime 
the flooding continued. When the forceps were put in his hands, he 
was baffled, as he told me, in adjusting them — the head retreating 
upwards whenever he attempted to apply them : after the loss of an 
additional portion of time — a fatal loss — he succeeded in seizing the 
head, and delivering the child, which was dead. The mother expired 
very soon after the birth of her infant. 

Some years ago, I was engaged by a tailor to take care of his wife 
in her approaching confinement ; he was an avaricious fellow, who 
disliked nothing more than the payment of a fee. In the middle of 
the night, his wife was seized with the pains of labor, which immedi- 
ately became violent and expulsive. He ran for an old woman in 
the neighborhood, who arrived just in time to receive the child, which 
she severed, and immediately proceeded to wash and dress it, leaving 
the woman lying upon the bed. "A-hah!" said the tailor, "this is a 
very good thing; we'll cheat the doctor out of his fee." And so he 
rejoiced and was very glad ; but in a short time the poor woman 
fainted, and remained for a long time insensible ; whereupon, taking 
the alarm, he came for me in furious haste, telling me that his wife 
was either dead or dying, and begging me, for God's sake, to give 
her speedy assistance. I very soon reached the apartment, and found 
her speechless and pulseless, and pale, and lying in a puddle of 
coagula and fluid blood ; placing my hand upon her abdomen, I found 
that there was another child there. I now took away all her pillows; 
opened the windows ; dashed water freely upon her face and neck ; 
and with difficulty succeeded in getting down a few swallows of strong 
brandy and water : the head presented, I ruptured the membranes, 



446 CONDUCT OF PRETERNATURAL LABOR. 

and passing my hands upwards to the feet, seized them, turned, and 
delivered the child; and immediately afterwards removed the pla- 
centas. I was for some time doubtful whether she would live or die, 
but she finally rallied under stimulation, and got quite well. 

I think that four minutes had not elapsed from the time that I 
reached her apartment until the child was delivered. Suppose that I, 
like my friend mentioned in the former case, had sent to my house for 
the forceps, would my patient have survived ? Suppose that he, in- 
stead of sending for his instruments, had immediately delivered her 
by turning, would he have lost both the mother and her child? It is 
said, that it is the last straw that breaketh the mule's back. It might 
as well be said, that it is the last ounce that kills in the uterine hem- 
orrhage. 

Having now described the operation for delivery in preternatural 
labors, the head presenting in the first vertex position, I have to 
indicate the method of proceeding in the other positions of the vertex. 
In all important particulars of the management, the former directions 
may be regarded as sufficiently full. But, as in the second position, 
the face of the child looks towards the left sacro-iliac symphysis, it is 
necessary, on that account, to employ in the turning, the right hand, 
and not the left hand, as before. 

By introducing the right hand, for the operation, the head will be 
pushed out of the plane of the strait to the right upwards, and made 
to lodge in part upon the brim, and in part upon the wrist and inner 
face of the forearm, while the fingers, going up along the breast and 
belly of the child, seek for, and at length find, the feet. 

When caught, one or both the feet are to be brought out at the os 
uteri into the vagina, and so through the ostium vaginae. Due care 
should always be used, not to force the version while the uterus is 
contracting. It may be expected to contract several times during the 
act of turning. 

Inasmuch as the face looked to the left sacro-iliac junction at the 
beginning, it might be expected, when completely turned, to look 
towards the right acetabulum, and it would probably do so, if care 
were not taken to draw chiefly upon the left foot ; by doing which, 
the left trochanter will be brought to the arch, and then it may, as 
soon as it has completely come forth, be forced over towards the right 
ischial ramus, which will serve to bring the left shoulder also to the 
right acetabulum, when that part begins to engage. The face of the 
child will of course, under these circumstances, be turned to the right 
sacro-iliac junction, and finally sink into the hollow of the sacrum. 



PRETERNATURAL LABOR. SHOULDER. 447 

I need not here reiterate directions, already sufficiently explained and 
insisted on in the former article. 

The operator may find the child that he is about to turn, present- 
ing in the fourth position of the vertex, in which case the forehead will 
look to the left acetabulum and ^the vertex be directed to the right 
sacro-iliac junction. In order to turn in this position of the child, he 
should employ the right hand, which, passing up on the left side of 
the pelvis, between the face and the brim, thrusts the head towards 
the right and anterior semi-circumference of the strait, where it 
must be resisted by the wrist or arm, w T hile the fingers explore the 
cavity in search of the feet. If the child were turned without being 
rotated upon its axis, its face, after the version, would be at the right 
sacro-iliac junction, and this would be well ; but still, in order to 
ensure an occipitoanterior position of the vertex after turning, it 
would be safest to act chiefly upon the left foot in making the trac- 
tions. I shall not repeat the directions for the other parts of the pro- 
cess. 

In the fifth position the fontanelle is found at the left sacro-iliac 
junction, and the top of the forehead at the right acetabulum. If the 
woman w r ere lying on her left side and the accoucheur seated with his 
face turned in the opposite direction to hers, he might, very conveni- 
ently, employ his right hand in version, for the palm of the hand 
slightly pronated would glide along the right side of the breast and 
abdomen of the child in search of the feet, which then might readily 
be drawn down. The child, having been completely turned, would 
have its face addressed towards the left posterior part of the womb ; in 
making the last tractions, therefore, the Student ought to be advised to 
draw chiefly upon the right foot in order to bring the right trochanter 
to the pubic arch, and, as soon as it shall have been fairly expelled, 
turn the trochanter towards the left ischial ramus, which will secure the 
descent of the shoulder in the neighborhood of the left acetabulum, 
and the subsequent engagement of the head in an occipito- anterior 
position. There is no necessity for repeating the minute directions 
as to the conduct of this version. 

In cases of version in the third and sixth positions, cases never 
likely to occur, the accoucheur could use either the right or the left 
hand, as he might deem most convenient to himself; the choice being 
indifferent, the occipitofrontal diameter of the child coinciding with 
the antero-posterior diameter of the pelvis. 

Turning in Shoulder Presentations.— The turning and delivery 



448 



PRETERNATURAL LABOR. — SHOULDER. 



Fig. 97. 




of the child in head presentations, are less difficult than in the ope- 
ration which is required for version in shoulder cases. 

In a former part of this volume, I have stated that there are two 
shoulder positions for each shoulder, making four in all. There are 
two positions for the right shoulder. In the first the head of the child 
is on the left side of the pelvis, as in the annexed Figure 97. This 

figure represents a shoulder presenta- 
tion with the right hand prolapsed ; 
the palm of the hand will look to- 
ward the mother's back and its dor- 
sum towards the front of her pelvis; 
the face looks backwards, and the 
feet of the child are in the back part 
of the womb, so that in seeking for 
them, the accoucheur should pass his 
hand along the breast of the child, 
and expect to find the feet not far 
from the sternum of the infant. To 
pass the hand between the child and 
the pubes would be to make a distressing mistake, for it would be 
impossible to turn the child in that way, and it would be wrong to 
expect to find its feet lying upon its back. To perform version the 
woman should lie upon her back, the hips being near to the edge of 
the bed, the thighs abducted, and strongly flexed upon the pelvis: 
the right hand should be chosen, (to look at Fig. 97 is enough to show 
that the right hand is the preferred one,) for the points of the fingers 
easily direct themselves towards the pelvic extremity of the foetus ; 
and the moderate supination of the limb applies the hand to the breast 
and abdomen of the child; the fingers could scarcely close between 
the abdomen of the child and the posterior aspect of the womb, 
without grasping the feet or knees, whereas, to use the left hand 
w T ould be to point the fingers towards the cephalic extremity of the 
foetus, and if the feet should be caught in that way, it would be ne- 
cessary to let thern go again. Therefore, in the first position of the 
right shoulder presentation, the Student will be careful to employ his 
right hand for version. 

Suppose the Student, in performing this version, should take hold of 
the left foot of the child, he would (let him look at Figure 97), cause it 
to revolve upon its axis and bring its face towards the mother's abdo- 
men. This is what he desires not to do, for the chief intention which he 
should set before him, is that of bringing the vertex to the symphy- 



PRETERNATURAL LABOR. SHOULDER. 



449 



Fig. 98. 




sis, and the face to the sacrum. He ought to get both feet, if possible ; 
having both feet in his hand, it will be in his power to draw the child 
by the right foot, which will bring the right trochanter to the pubic 
arch, and the right shoulder to the left acetabulum, which will let the 
face come into the pelvis looking backwards towards the left. 

The second position of the right shoulder presentation is neatly 
figured in the accompanying drawing, 
Fig. 98. It represents the body of 
the child very much compressed by 
the contracted womb, from which the 
waters have been expelled, and the 
hand of the accoucheur, which is here 
the right hand, partially engaged in 
the cervix uteri, seeking for the feet. 
It would be as well, in this particular 
labor, provided the patient w T ere lying 
on the back, to use the left hand in 
version ; but, if she were lying upon 
her left side, the right hand would 
be far more convenient than the left, 

since, introduced between pronation and supination, it would apply 
itself to the breast and abdomen of the child. 

Fig. 99 shows the process of operation, which is here being pro- 
perly conducted, for the tractions are 
being made upon the left limb, which 
would serve to roll the child upon its 
axis so as to turn its face towards the 
posterior semi-circumference of the 
pelvis. 

The left shoulder presentation has, 
likewise, two positions. In the first of 
them, the head is directed towards the 
left side of the pelvis, and the face of 
the child looks front. In the second, 
it is directed toward the right side of 
the pelvis, the face looking backwards. 
In the first position, the left arm being 
down, the feet should be found between 

the belly of the child and the anterior wall of the womb ; the rule 
obtains, therefore, in this as in all cases, of passing the exploring 
hand upwards along the front of the child's body. If the woman 
29 



Fig. 99. 




450 



PRETERNATURAL LABOR. SHOULDER. 



Fig. 100. 



were lying upon her left side, with her knees drawn up with a pillow 
between them, the palm of the right hand would readily apply itself 
to the anterior aspect of the foetus : the left hand would be highly in- 
convenient for this operation; it might be used in the dorsal decubitis, 
but not so conveniently as the right. 

The child's face is looking to the front ; it ought to be rolled upon 
its axis so that the face may look backwards, giving it at last an 
occipitoanterior position; therefore, let the operator make his chief 
efforts upon the right inferior extremity, which alone can roll it upon 
its axis. 

In the second position of the left shoulder presentation, the face is 
on the right side of the pelvis looking backwards, the left shoulder 
downwards, the hand or elbow prolapsed or not; it is indifferent 
whether they be or be not prolapsed. 

Figure 100 explains the operation: the left hand is employed, for 

its fingers go out. towards the pel- 
vic extremity of the child, and its 
palm, in easy pronation, adapts itself 
to its anterior aspect. If the Student 
should draw the child down by the 
right inferior extremity, he would roll 
it on its axis. This would be wrong, 
since the child's face is already back- 
wards; let him, therefore, make his 
chief tractions by the left limb, in 
order to bring the left inferior ex- 
tremity to the symphysis, which, after 
it is born, should be twisted towards 
the right ischium, which will serve to 
bring the face into the hollow of the sacrum at last. 

I ought not to omit some reference to an accident which occasion- 
ally happens, whether in version or in original pelvic presentations. 
I allude to the locking of the head above the brim of the pelvis, which 
becomes keyed there by the forearm; the elbow being elevated, and 
the hand projecting backwards beyond the nucha, serves as a key to 
prevent the head from sinking into the excavation. When the pres- 
sure, in consequence of aggravated contractions of the womb, be- 
comes very great, it is nearly impossible to disengage the hand from 
behind the neck, by depressing the elbow by means of the fingers in 
the way formerly pointed out; — it is easier to break the delicate bone 
of the humerus than to bring the elbow down. Dr. Dewees' method, 




PRETERNATURAL LABOR. SHOULDER. 451 

one upon which he very strongly insisted in his lectures, was to pass 
two fingers upwards in front of the shoulder-joint, and two fingers up 
against the opposite scapula. By means of the pressure in contrary 
directions of these two opposite hands, the thorax of the child is made 
to revolve upon its axis one quarter of a circle ; the hand is disengaged 
from behind the throat by this rotation, and immediately afterwards 
brought down by pressure at the bend of the elbow. 

It has been proposed to restore the head to the brim of the pelvis, 
in cases in which it has deviated, so as to allow another part of the 
foetus to present itself there. I have on different occasions attempted 
to succeed in this version by the head, but have always signally failed, 
with the exception of a case which I have already related in a former 
page of this work. In that instance I succeeded by means of pressure 
made upon the external surface of the abdomen. The attempts might 
always be made with propriety in those cases in which the contrac- 
tions of the w T omb have not as yet driven the presenting parts firmly 
into the opening. With a loose and flaccid uterus, the Student might 
have the good fortune, after lifting the shoulder out of the way, to 
lodge the head fairly in his palm, and pushing the fundus uteri in an 
opposite direction so as to raise the breech of the child, draw the head 
to the abdominal strait and let it engage therein. I think no very 
violent efforts should be made to effect this kind of version. 



452 DEFORMED PELVIS. 



CHAPTER XIV. 

PRETERNATURAL LABOR FROM DEFORMED PELVIS. 

The thirteenth chapter of this volume, on the subject of preterna- 
tural labor, has been drawn out to so great a length, that I brought it 
to a close upon the last page; and I did so because I have at present 
to enter upon the consideration of those preternatural labors that are 
rendered so by deformities of the osseous pelvis, and also by fleshy 
and fibrous or other tumors, that, growing from the walls of the pelvis, 
or that, having fallen down into its cavity from above, impede, obstruct, 
or wholly prevent the completion of the parturient act. 

In a former part of this work, to wit, in Chapter I., I have already 
treated of the pelvis as normally constituted. The Student, from 
reading that chapter, has become acquainted with the dimensions of 
the planes of the two straits, and the capacity of the excavation. 

The Student knows that the osseous frame consists of a soft gela- 
tinous material which hath become rigid and extremely solid and com- 
pact by the deposit within it of portions of phosphate of lime. He 
knows that to macerate a bone in a strong acid solution is to dissolve 
out from it entirely the whole of its calcareous and solid matter, leaving 
to the bone its pristine form and dimensions, but leaving it, at the 
same time, compressible and flexible in every direction ; for all that 
is left of the bone after the maceration is a gelatinous mixed with a 
proportion of fibrous and cellular material. 

Now the child that is born may become, in one of the early years 
of its existence, the subject of a disease one of whose most prominent 
characteristics is to prevent a deposition of the calcareous phosphate 
in the substance of the gelatinous framework of the bone; not wholly, 
indeed, but to such a degree as to leave the bone softish and com- 
pressible, or flexible. Again, a child may grow up in apparent health, 
having conformably developed all the parts of its constitution — its 
phosphatic deposits having been rendered complete up to a certain 
term, and giving to its bones a due degree of solidity and firmness; 



DEFORMED PELVIS. 453 

whereupon it shall be attacked with disease, whose effect shall be to 
remove from the gelatinous framework of its bones a large proportion 
of its calcareous solid. 

These two cases present examples, the one of a suspension of the 
process of deposition, and the other of a removal of the phosphates 
already deposited. The former is Rachitis, or Rickets. The latter is 
Mollities-ossium, or softening of the bones. The effect is the same 
in either case. In rachitis, the child continues to grow without re- 
moval of the ancient phosphate, and the bone bends or is crushed. 
In the latter, the ancient phosphate is removed, and the bone bends, 
or is crushed. It bends, or is crushed under superincumbent weight. 
If the child laboring under rachitis should recover from that malady, 
it would regain its power to solidify its bone, by depositing calcareous 
matter within its intimate structure. But, should the solid matter be 
replaced while the bone in its plastic condition is pressed or bent out 
of its due shape, it might regain the most consummate health, and 
remain ever after affected with deformity of the bone in question. 

If the humerus, the radius, the femur, or the tibia, should regain 
its solid phosphate, those several bones would be found arcuated — 
bent like a bow — and remain ever so. If the ossa innominata, which 
consist of the ilia, ischia and pubes, should be the seat of the soften- 
ing processes, and if, during a long-protracted illness, the child should 
lie chiefly upon her right side, or upon her left buttock, the sacro-pubal 
diameter of the pelvis would allow its pubic extremity to be turned 
towards the right side of the child, and vice versa. This would pro- 
duce what is called the obliquely-deformed pelvis — dass schraage 
verengte beckens — of Professor Naegele of Heidelberg. 

The Student will perceive that such a pelvis as this must lose a 
portion of that diameter which extends from the left acetabulum to 
the right sacro-iliac symphysis, provided the pubis be deflected to the 
right side, and so, mutatis mutandis. 

In case the Student should be charged with the conduct of labor 
for a woman affected with right oblique-deformed pelvis, he will per- 
ceive the necessity there is to direct, if possible, the vertex of the 
child to the right rather than to the left acetabulum of the mother ; 
for as the occipito-frontal diameter of the foetus exceeds its bi-parietal 
diameter, he would sedulously endeavor to make the greatest diameter 
of the head coincide with the greatest diameter of the pelvis, in order 
to render the delivery comparatively facile, which would be difficult, 
laborious and even impracticable, were he to persist in attempts to 
force the long diameter of the head through the contracted diagonal 



454 



DEFORMED PELTIS. 



Fig. 101. 



of the pelvis. This is one of the cases in "which turning and delivery 
by the feet are allowable in the deformed pelvis. 

Having made a perfect diagnosis of the deformity, he will find him- 
self able, in performing the act of version, to adjust the smallest dia- 
meters of the foetal cranium in such a way as to make them coincide 
with the smallest diameters of the pelvic passages. 

The annexed figure is taken from Professor Naegele's work on the 

oblique deformed pelvis. 
It is seen, by inspection of 
the figure, that if the ver- 
tex of the child should be 
directed towards the left 
acetabulum, the dimen- 
sions of the pelvis are so 
much diminished by the 
fall of the pubis towards 
the right, that little expect- 
ation could be indulged of 
the descent of the cranium 
below the plane; for the 
antero-posterior diameter 
of the cranium exceeds four inches and a half, while the bi-parietal 
diameter is 3.88. 

I subjoin the figure of a pelvis preserved in my collection (Fig. 
102). It will be seen that it is right oblique-deformed, like that de- 




Fig. 102. 




DEFORMED PELVIS. 



455 



scribed by Professor Nsegele. I give the figure of it in order that I 
may set down on this page its dimensions, which I now carefully 
measure. 

From the promontory of the sacrum to the top of the symphysis 
pubis, 3.6; from the promontory of the sacrum to the point of the 
coccyx, 3.5 ; from the right acetabulum to the left sacro-iliac junction, 
4.1; from the left acetabulum to the right sacro-iliac junction, 2.7; 
from the top of the right ischium to the top of the left ischium, 3.7; 
from the inner lip of the right tuber ischii to that of the left tuber 
ischii, 3.5; from the point of the coccyx to the crown of the pubal 
arch, 4.2 ; from the point of the coccyx to the inner lip of the left 
tuber, 1.9, to the right tuber, 3.5 ; the length of the symphysis pubis, 1. 

I shall proceed now to speak of other deformities of the pelvis. 
Rachitis or Mollities does not ne- 
cessarily affect the whole of a 
bone. The figure 103, which I 
subjoin, represents the plane of 
a superior strait like the figure 
8. It is evident upon inspection 
that the posterior semi-circum- 
ference of the pelvis has not suf- 
fered at all in its form, as the 
Student may perceive by comparing it with Fig. 104, which I have 




Fig. 104. 




taken from the pelvis of an Egyptian lady of rank from the tombs of 
Thebes, which pelvis was presented to me by my friend, Samuel 
George Morton, the distinguished author of the " Crania Americana." 
This pelvis, which is one of the most perfect specimens of the female 
pelvis that I have ever seen, may serve here as a means of comparing 



456 



DEFORMED PELVIS. 



the posterior semi-circumference of the badly deformed pelvis, Fig. 
103, with the posterior semi-circumference of this most perfect Egypt- 
ian form. It shows that the deformity in Fig. 103, has arisen from 
rachitis or mollities affecting chiefly the pubal and ischial portions of 
its ossa innominata, which, having fallen inwards upon the promon- 
torium of the sacrum, have so reduced the antero-posterior diameter 
of the superior strait as to render the passage wholly impracticable 
for the full-grown foetus. 

In such a pelvis as this, the pregnant woman ought to be advised 
to submit to an early abortion, whereby she w T ould be preserved from 
an ultimate direful necessity to undergo a frightful Csesarian operation, 
because, when the antero-posterior diameter of the pelvis is only an 
inch and a half in length, it is impossible to extract through it a full- 
grown foetus, except that foetus be either of an under size or else in 
a state of absolute decomposition ; circumstances not to be expected, 
and therefore not to be relied upon, nor scarcely to be hoped for. Dr. 
Simpson's late case, published in an English Journal, might serve 
rather to mislead the practitioner with vain hopes of an unparalleled 
good fortune like that which his patient enjoyed, than as a precept to 
be generally followed. 

I annex the figure of another pelvis (Fig. 105), in which the dis- 
tortion has attacked the sa- 
crum itself, as well as the 
pubes and ischia, and par- 
tially the left ilium. In 
such a pelvis as this, pro- 
vided the antero-posterior 
diameter should not be re- 
duced below three inches, 
good hope might be enter- 
tained of extracting a living 
child by means of dexterous 
and most patient use of the 
obstetric forceps ; especial- 
ly should the child be rather under size and one in which the progress 
of ossification had not gone so far as to render the bones of the cra- 
nium very firm and resisting. But, as a child's head in its bi-parietal 
diameter, according to my measurements, will average 3.88, and as, 
in a series of three hundred heads, I found but one under 3.50, there 
will be in general but faint prospect of extracting a full-grown child 
alive. The records, however, contain abundant examples of cases 




DEFORMED PELVIS. 457 

in which the fetus at term was spontaneously expelled in pelves re- 
duced as low as 2.50. In the treatment of such a case as the one 
now under consideration, the least reflecting Student must perceive 
that, in adjusting the position of the head, it would be desirable for 
him to bring the bi-parietal diameter, which is the smallest diameter 
of the head, in coincidence with the antero-posterior, which is the 
smallest diameter of such a pelvis; and further, that in any attempt 
to assist the natural powers by means of the obstetric forceps, it would 
be preposterous for him to think of adjusting the blades upon the sides 
of the head in that direction. The pelvis is already, perhaps, fatally 
small. To apply the blades of the forceps, then, would be considerably 
to increase the necessity for the reduction of the transverse diameter 
of the head. Common sense, therefore, would teach him that if he 
must apply the additional force, it must be applied to the face and 
occiput of the child. The blades of Davis's forceps, even when the 
handles are perfectly shut, are 3.9 asunder. It would be impossible, 
therefore, to extract the forceps in that direction, much more the head 
contained within them. 

I believe that the practitioners of midwifery in England are less 
familiar with the use of the forceps than those of the continent or of 
the United States. I think them quite too prone to refer to the aid of 
the crotchet and perforator; and I cannot but indulge a disposition to 
dissent from their almost invariable habit of adjusting the blades upon 
the sides of the head, much preferring the practice of the continental 
physicians and those of the United States, who seize the head upon 
the sides of the pelvis — a practice as to the safety of which I con- 
fidently speak from multiplied opportunities in my clinical experi- 
ence. 

This is a case, also, in which, perhaps, more properly than in other 
cases, the precept should be observed of attempting to deliver by 
turning. Those who, in restricted pelvic diameters, propose the re- 
sort to turning as a means of saving the child, and at the same time of 
preserving the woman from much pain and greater danger, insist upon 
it that the chance of preservation is greater, because when the child has 
been turned and drawn away, so as to allow the head to come to the 
narrowest part of the pelvis, the cranium yields, allows its diameters 
to be reduced, and may be disengaged from a narrow strait, through 
which it could not be driven if the head were the presenting part. 
The idea is this : when the head is drawn through by means of traction 
exerted upon its neck, it undergoes a process which, as I take it, is 
not wholly unlike that called wire-drawing, whereas, when the head 



458 DEFORMED PELVIS. 

presents, such a process of wire-drawing cannot be supposed readily 
to take effect. A portion of metal can readily be drawn through the 
apertures of a wire-plate, which no art could drive through it from 
the other side. 

I am not prepared in this place to go so far as Professor Simpson 
of Edinburgh, in recommending a resort to version in bad pelves, and 
my hesitation arises from this, that the mensuration of the pelvis 
being rather a non-dependable process, there is reason to fear that 
the incautious and inexperienced accoucheur might, by too free a 
recommendation of it, be led to institute this method in cases where 
the reduction of the diameters is so considerable as to render an ex- 
cerebration indispensable for the delivery. I admit that it is possible 
to effect an excerebration in the footling case ; but in every case of 
a badly deformed pelvis, that operation implies an exceeding great 
risk of detruncation — an accident the most to be deprecated, for what 
occasion can arise for embarrassment and vexation greater than that 
which he experiences who is condemned to the task of extracting a 
detruncated head through a very much reduced superior strait of the 
pelvis ! 

In Dr. Lee's 3d Report Clinical Midwifery, p. 74, 3d ed., he gives 
the account of several cases of footling labors, occurring in deformed 
pelves, in which he was obliged to diminish the head by opening the 
cranium through the occipital bone. In some of these cases, that 
able and most dexterous practitioner frequently found himself greatly 
embarrassed in effecting the operation. To read his accounts of the 
cases w T ould be sufficient to put the Student upon his guard against 
the risk of encountering those embarrassments from version in de- 
formed pelves of which I have spoken. 

Here is another pelvis, Fig. 106, in which the rachitis has attacked 

the whole organ, for the last 
lumbar vertebra, as well 
as the ilia, ischia andpubes, 
are all changed in shape. 
The horizontal portions of 
the pubes have become al- 
most parallel, narrowing, of 
course, the antero-posterior 
diameter of the pelvis, and 
approximating the extre- 
mities of the transverse as 
well as the oblique diame- 




DEFORMED PELVIS. 459 

ters, so as to render hopeless any attempts to extract the living child 
through it. 

It appears to me to be needless to follow the example of those writers 
who have reduced the deformities of the pelvis into a sort of classifi- 
cation. It is evident that the softening of the bones, which, as I have 
already said, may attack the whole or any part of the osseous struc- 
ture of the basin, may yield every conceivable degree of irregularity 
of form ; and those that I have already spoken of in this article are 
sufficient to show the Student what is the nature of these deformities; 
and as he is already acquainted, from a former chapter in this volume, 
with the mean dimensions of the foetus, he maybe regarded as already 
qualified to give his judgment upon questions of the obstetrical ope- 
rations arising under pelvic deviations. 

It is necessary that he should be aware of the methods which are 
adopted for ascertaining in the living woman the dimensions of the 
pelvis. As a general rule, the indicator finger of the accoucheur 
will scarcely be found capable of extending further than three and 
a quarter inches or three and a half inches beyond the crown of the 
pubal arch. It is true that by the introduction of half the hand, 
the palp of the indicator finger can be made to explore a region 
four and a half inches distant from the crown of the arch ; but, as the 
introduction of half the hand in the woman not in labor, or affected 
only with the earliest stages of labor, is so painful as to excite the 
greatest repugnance and resistance on the part of the patient, the 
vaginal taxis is generally preferred with the indicator alone. 

Suppose there should be some suspicion of a degree of deviation of 
the pelvis — one in which the pubis has retreated 
towards the sacrum, or one in which the pro- g ' 107 ^ 

montorium has descended towards the sym- 
physis pubis. If he should carry his indicator 
finger as in the annexed figure, directing it to- 
wards the promontory of the sacrum, and in vain 
therewith endeavor to touch the sacro-vertebral 
angle, his exploration will teach him at once and 
clearly that his patient has nothing to fear on this 
head; but if he can readily touch it, as in the 
figure, then he has a deformed pelvis, proportion- 
al to the facility of the touch. 

If, again, the point of the coccyx, which can 
always be touched with the indicator finger, is found not to approach 
too close to the crown of the pubal arch, uneasy apprehensions on 




460 



DEFORMED PELVIS. 



Fig. 108. 



this head are at once set aside. As for the mensuration of the 
transverse diameters of the inferior strait of the pelvis, the least tact, 
with but little experience, would show that that strait is or is not 
normal, and to what degree, if deviated at all. 

If, however, upon introducing the index finger, it should at once 
encounter the sacro-vertebral angle, pressing the point of the finger 
against the protuberance, and lifting its radial edge up to the crown 
of the arch, with the finger nail of the other hand he can mark the 
point of contact with the top of the arch, and then, measuring the 
distance to the point of the finger, he will have an accurate report as 
to the antero-posterior diameter. 

It appears to me that there is no necessity for the Student in this 
country to trouble himself to make a provision of callipers to measure 
the pelvis externally, in order to get a report of the internal diameters 
of it, nor need he, in my opinion, procure any intro-pelvimeter, which 
is more apt to mislead him than his hand is; and which, moreover, is, 
both inconvenient and painful in its application. Nevertheless, if he 

should be inclined to avail himself 
of the use of the callipers, he will 
perceive in the annexed figure the 
mode of its application. Applying 
one of the buttons of the calliper 
to the symphysis pubis, and the 
other to the spinous process of the 
fifth lumbar vertebra, the scale will 
mark the space by which the buttons 
are divided. Let him subtract from 
that space half an inch for the thick- 
ness of the symphysis pubis, and 
two and a half inches for the space 
between the sacro-vertebral angle 
and the spinous process on which 
the button rests, he will have three 
inches to deduct from the whole 
sum ; the remainder is to be taken as the antero-posterior diameter of 
the plane of the superior strait. If he will please to refer back to 
Fig. 103, in which the pubis projects in consequence of the parallel- 
ism of its horizontal rami, he will at once perceive the futility of an 
attempt to deduce the internal capacity of the pelvis from an external 
measurement. 

The great matter is for him to determine the indication of treatment 




DEFORMED PELVIS. 461 

in the case, and that indication must clearly arise from a consideration 
of the actual state and wants of the patient, and not from any rules 
or precepts that can be set down in any book whatever. A gentleman 
might, for example, be impressed with the propriety of trusting to 
the unassisted powers of nature in a patient whose antero-posterior 
diameter at the superior strait is three or even less<than three inches, 
and he would be led to do so from an opinion he should form of the 
ability of the woman to support for a long time the efforts and the 
irritation of a most laborious labor; whereas, in another patient having 
a pelvis of precisely the same dimensions, he should perceive the 
most urgent necessity to deliver immediately, in order to preserve her 
from an otherwise inevitable death. 

Besides the deformities of the pelvis from mollities ossium and 
rachitis, there are other affections of the capacity of the basin which 
are produced by bad arrangement of the form of the pubic arch- — cases 
in which the arch is Saracenic, and not Roman; the descending rami 
of the pubes, instead of divaricating so considerably as to allow the 
rounded occiput to rise quite up into contact with the triangular liga- 
ment of the pubis, here compel it to descend far below the crown of 
the arch, in order to extend itself and be born. 

Such a condition of the arch of the pubis is precisely equivalent to 
a preternaturally long symphysis of the bones. The easiest labor, 
cceteris paribus, is that in which the symphysis pubis is the shortest — 
that in fact in which the symphysis is but a narrow bar under which 
the head has an early opportunity to be extended, as the third act in 
the mechanism of the head in the pelvis. In all cases where the arch 
is very narrow, and the head compelled, in consequence thereof, to 
descend very low previous to commencing its act of extension, the 
distress of the patient and her hazard are considerably augmented by 
the concurrent necessity of thrusting the perineum so much further 
down as the head is compelled to descend, previous to commencing 
its act of extension. 'I have seen labors in which the woman made 
the most desperate efforts at expulsion before success could crown her 
exertions, and I have been compelled, in consequence of this species 
of deformity, to exert all my strength and dexterity to extract the 
foetal head with the forceps. 

I have said, in another page, that the obstetrical properties of the 
pelvis depend mainly upon the conformation of the anterior aspect 
of the sacrum. Where its curve is too great, the point of the coccyx 
interferes with the antero-posterior diameter of the inferior strait, 
and where the curve is too small, that most important act in the 



462 



DEFORMED PELVIS. 



mechanism, to wit, the rotation of the head, is rendered difficult, if 
not indeed impossible. I speak, from painful experience, of the diffi- 
culties I have encountered from this cause, in cases in which, having 
found the spontaneous rotation not possible, I have been compelled 
to effect it by locking the child's head in the blades of the forceps, 
and then, with a difficulty and cautiousness, and slowness and doubt 
calculated to impress my mind with a sentiment not very different 
from one of horror, and with protracted efforts, finally crowned by suc- 
cess as to the mother at least — and sometimes, both for the mother 
and child — have thanked God for their escape. On the 5th of January, 
1849, I delivered a lady — the same one whose case is mentioned on 
page 29 — of her seventh child. It was the fifth forceps operation re- 
quired in her case. The child's head measured, in its occipito-mental 
diameter, six inches; its occipito-frontal was 5 2 9 Qths, and its bi-pa- 
rietal 4 3 9 IJ ths. There was no rotation. The left-hand blade of my 
forceps was applied upon the occipital region, and the right-hand 
blade upon the frontal region. After the most exhausting efforts on 
my part, and unspeakable suffering on hers, the child was delivered 
with its vertex to the left tuber ischii, and its forehead to the right. 
To-day, January 9th, the mother and child appear to be in perfect 
health. 

Notwithstanding I have already, at page 289, spoken of those cases 
of labor rendered preternatural by prolapsion of the bladder, more 
properly to be called vaginal vesicocele, to which I beg here to refer 
the Student, I annex a drawing, (Fig. 109,) 
which may serve to show the mode in which 
the over-distended bladder may get beneath the 
head so as to prevent its descent. The most 
fatal consequences might ensue from a mis- 
take in the diagnosis of this case, of which the 
remedy is to be found in the use of the catheter. 
In a former part of this book, is contained 
an account of a case that occurred to me in 
consultation with Dr. Bicknell — that of a wo- 
man in whom a large mass of intestinal con- 
volutions had fallen down below the uterus and 
filled the cavity of the pelvis, occupying the recto-vaginal cul-de-sac, 
and distending it to an enormous size. This was a cause which con- 
verted an otherwise perfectly healthy labor into a preternatural one. 
I think it probable that the woman would ultimately have fallen into 
a state of exhaustion, or that she would have developed inflammation 



Fig. 109. 




DEFORMED PELVIS. 463 

in the mass of strangulated intestinal convolutions, had not the cause 
of difficulty been ascertained, and the labor brought to a rapid con- 
clusion by the return of the prolapsed bowel into the cavity of the 
abdomen. It is proper to cite the example in this connection, were 
it merely to indicate to the Student the possibility of such an occur- 
rence, and the necessity of interference in the case. I shall dismiss 
the subject, merely referring the reader to the page above mentioned. 

Cases are mentioned of labors rendered preternatural by the en- 
gagement of a firm tumor, consisting of altered ovary occupying a 
very considerable part of the excavation of the pelvis, preventing the 
descent and passage of the head. The rule of action should be, 
under such circumstances, to endeavor by all the means in one's 
power to return the tumor above the strait ; and, as such a tumor 
must necessarily be behind the uterus, and not at the side or in front 
of it, the attempt to push it out of the w T ay would be far more likely 
to succeed, were the patient placed upon the knees, the top of the 
breast being pressed upon the same plane on which the knees rest : 
the pelvis being thus elevated, the uterus would be by gravitation 
drawn far upwards out of the pelvis, leaving a more ample space for 
the reposition of the tumor, and it should further be observed, that 
the patient placed in this position is completely deprived of the tenes- 
mic power, or the bearing-down power, a slight exertion of which 
would be sufficient in almost any case to contravene the efforts of the 
practitioner. In all such cases, then, I advise the Student to cause 
his patient to be placed in the position above indicated, and then, with 
the hand in the vagina or one or two fingers in the rectum, endeavor 
to displace the tumor upwards. 

It has been recommended, where displacement of the tumor up- 
wards proves to be impossible, to endeavor to reduce its magnitude 
by puncturing it with a trocar, or incising it with a bistoury through 
the posterior wall of the vagina. I do not feel at liberty to recommend 
such an operation in this volume — an operation which could only be 
legitimately performed, upon due and mature consideration with the 
most acute and able practitioners of the vicinity. They alone should 
feel themselves vested with the authority to act under such terrible 
circumstances. I may merely remark, en passant, that an incision 
into the posterior wall of the vagina, should it even have the good 
effect sufficiently to reduce the size of the tumor, fearfully exposes 
the patient to the risk of vaginal laceration from the subsequent dis- 
tension by the descending head, and the escape of the child into the 
peritoneal sac. A small aperture in the thin posterior paries of the 



464 DEFORMED PELTIS. 

tube, is more likely to yield and become a frightful laceration, than 
to resist the distending force of the advancing head. I consider my- 
self fortunate in not having met, up to this time, •with a case of 
enlarged and hardened ovarian tumor or fibrous tumor occupying and 
rendering impracticable the pelvic cavity. 

I saw, in consultation with Dr. Beesley of this city, a lady in whom 
a large heterologue mass seemed to spring from the left semi-circum- 
ference of the brim of the pelvis and iliac fossa, overhanging appa- 
rently nearly one-half of the plane of the superior strait. When the 
labor came on, the bag of waters was formed, the vaginal cervix be- 
came farciminal or cylindrical, so that, having got beneath the over- 
shadowing mass, it lifted it upwards and turned it over to the left side, 
permitting the head to fall into the chasm of the excavation, whence 
it was soon happily expelled. After the birth of the child, the tumor 
resumed its former position. 

Laceration of the Womb and Vagina. — The present caption indi- 
cates the most terrible accident which can happen to women in labor. 
The uterus in some instances yields to the force of non-coordinate 
contractions; certain portions of the organ proving stronger than cer- 
tain other portions, the weaker portion may be supposed to lose its 
muscular power of resistance, whereupon its mere textural resistance 
becomes incompetent to resist the strain upon it, caused by the con- 
traction of the most perfect and contracting parts ; it grows thinner, 
and then a solution of continuity takes place, and a rent or laceration 
of greater or less extent, exposes the patient to the frightful risk of 
discharging the child and the contents of the womb into the peri- 
toneal sae, among the convolutions of the bowels. 

It appears to me far more probable that these lacerations, or rup- 
tures, as they are called, will commence in the posterior wall of the 
vagina, nigh to the cervix uteri, where the vaginal wall consists 
merely of the mucous body and vaginal cellular tela, resting upon 
a basis of peritoneum merely: the tube is so thin at this place 
that it is surprising to witness its power to resist in certain labors 
wherein women, to the amazing expulsive powers of the uterus, add 
the vast power which they are capable of exerting by means of their 
adjutory muscles. When this tissue becomes still more thin, as in 
being distended by a very large head, one would think that a fissure 
of a line in length might prove the beginning of a laceration in which 
the rest of the vagina and the vaginal cervix would give way like a bit 
of torn linen. In any such case, if the head or presenting part should 



PRETERNATURAL LABOR. — RUPTURED UTERUS. 465 

escape beyond the tube of the vagina, or the wall of the uterus, the 
pain will be likely to become greatly exaggerated by the stimulation 
of such an event ; and the uterus would make haste to free itself of 
its burden qua data porta. 

Upon the expulsion of the child and the contents of the uterus, the 
labor is at an end, quoad the uterus; the labor-throes cease, and a 
great calm immediately follows the accident, which is suspected to 
take place merely upon such a sudden and extraordinary cessation of 
the activity of the process, but which is known to have taken place, 
upon discovering that the presenting part is no longer to be detected 
in consequence of its having escaped from the cavity which detained it. 

In regard to the point of duty in the management of such cases, I 
have to remark that, upon discovering even the smallest commence- 
ment of a laceration of the vagina or cervix uteri, the earliest practi- 
cable precautions should be taken to ensure delivery per vias natu- 
rales, and the prevention of the escape of the child into the peritoneal 
sac. This should be done, where it is practicable and convenient, 
by seizing the head, if it be the head, in the grasp of the obstetrical 
forceps ; by bringing* down the feet, if it be a breech ; by turning 
and delivering, if it be a shoulder case ; or by turning to deliver, if it 
be a case of face presentation, or departure of the chin, or any condi- 
tion indeed in which the operation of version w T ould be most likely to 
rescue the woman from the dangers by which she is surrounded. 

Should the laceration have permitted the child to escape at once 
into the peritoneal sac, let the attendant lose no time, but bare his 
arm, and resolutely, with his hand passed through the rent, explore 
the abdomen in search of the feet, which he should immediately with- 
draw through the opening of laceration. But if this be not done ; if 
some hours should have elapsed subsequent to the occurrence of the 
accident ; if the woman be already much exhausted by hemorrhage, 
by constitutional shock and irritation, the question will arise as to the 
properest manner of fulfilling the indication, which must ever be to 
extract the child. The hemorrhage will now have been stayed : were 
it not so, the woman would be already dead : to pass the hand through 
the rent, should it be in the vagina, would be to set the hemorrhage 
again on foot. It will be always impossible to pass the hand through 
the rent in the uterus, because the uterus, being now contracted, will 
have reduced the size of the rent in proportion to the condensation of 
the organ. The child can never be returned through a contracted 
rent, having passed through it while the uterus was yet undiminished 
30 ■ 



466 PRETERNATURAL LABOR. — RUPTURED UTERUS. 

in size. I say, then, the question arises as to the mode in which the 
indication is to be carried out. 

I am firmly convinced, that, should I be called this day to the con- 
duct of such a case, I should feel bound by my conscience to recom- 
mend a delivery by a gastrotomy operation. I cannot think that a 
clean incised wound along the linea alba, sufficient in length to permit 
the extraction of the child from the peritoneal sac, however exception- 
able in itself merely considered, can be held in the least degree ob- 
jectionable when compared with the delay, the fatigue, the contusion 
and the renewal of the suspended hemorrhage, that would inevitably 
attend an attempt to extract per vias naturales. I express this opinion 
here upon a most vivid recollection of the distress which I occasioned 
to an unfortunate female, who, in consequence of a laceration affect- 
ing the posterior wall of the vagina and the vaginal cervix, drove her 
child into the cavity of the belly. As the head could be Touched, 
and as the child was dead — nearly twenty hours having elapsed since 
its escape from the uterus — I made use of the perforator, and then, 
taking hold of it through the opening with my embryotomy forceps, 
I used all the force which it was possible for me to employ in drawing 
it away through the natural passages. The unfortunate woman, who 
bore the rude operation with the greatest constancy and courage, 
lingered many hours after its close. The events of this case, which, 
peradventure, might have bad a happier conclusion by means of the 
gastrotomy operation, have impressed me, more than a thousand ar- 
guments could do, with a deep conviction of the cruelty of such a 
mode of delivery ; and I repeat here, in the most distinct terms, my 
decided preference for a delivery by means of an incision through the 
linea alba. 



THE FORCEPS. 467 



CHAPTER XV 



OF THE FORCEPS. 



"But yf all these medicines profite not, then must be used more 
severe and hard remedies, with instruments, as hokes, tongues, and 
such other thynges made for the nonce. And fyrst, the woman muste 
be layde along upright, the middle part of her bodye lying hier then 
all the rest, companyed with women assisting her about, to comfort 
her and to kepe her downe, that when the byrth is plucked out she 
rise not withall. Then let the Mydwyfe annoynt her lefte hande 
with the oyle of white Lillies, or other that may make it soople and 
smothe, and holding out her fingers, shutting together her hand, let 
her put it into the Matrix to feele and perceyve after what fashion the 
dead byrth lyeth in the Mother's wombe, so that she may the better 
put in hookes and such other instruments to plucke it out withall." 

"Yf it be that it lye the head forwarde, then fasten a hooke eyther 
uppon one of the eyes of it," &c. &c. 

The above quotation from the "Woman's Booke, or the Byrth of 
Mankynde," may serve to show the Student what was the notion of 
Midwifery in the glorious age of Queen Elizabeth. Thomas Rai- 
nald, the author of this quaint old English, is the earliest vernacular 
author on Midwifery. The volume from which I have made the ex- 
tract, was " imprinted London, 1565," 4to. Let the Student be thank- 
ful for the age in which he lives. He is not foreordained to the use of 
hooks and other such instruments in difficult cases, for in modern times, 
the resources of the obstetric art have been signally augmented by 
the discovery, and the great perfection attained in the construction 
and use of instruments for the forced delivery of the parturient 
woman. The ancients were not wanting in numerous inventions for 
expediting the birth of children, but, unhappily, all their instruments 
w r ere constructed with the sole view and intention of being useful to 
the mother, and had no applicability to the child, except to extract it 
after depriving it of existence, or even to draw it forth from the womb 



468 THE FORCEPS. 

still palpitating with life, and presenting the most shocking spectacle 
of mutilation and distress. The Uncus, or Crotchet, described by 
Celsus, continued, indeed, to be the model of obstetric instruments 
down to the close of the seventeenth century, when a happy thought 
resulted in the construction of an instrument most perfectly adapted 
to the security both of mother and child, and which, at the present 
day, and in the hands of skilful and well instructed persons, may be 
considered one of the greatest triumphs of art in behalf of suffering 
humanity. 

Perhaps one of the ideas that would most readily and spontaneously 
present itself, in a case of difficult labor with a head presentation, 
would be to take hold of the head and draw it forth ; and I believe 
that most of the good women who so assiduously apply themselves to 
exhort us to help our patients, actually do believe that we can take 
hold of the child's head with our fingers, and draw it into the world, 
as readily as we can draw a dollar out of our purse, or take an apple 
from a basket. But we cannot take hold of the head and pull it down,' 
simply because we cannot grasp an infant's head in the hand: we 
can apply our fingers to one side, and a thumb to the other side, and 
press it between them; but when we attempt to pull the head down, 
we find that the fingers and thumb are not long enough to admit of 
our grasping it; and we withdraw the hand, leaving the head just 
where it was before we made the attempt, and the woman so much 
the worse for the additional irritation of her organs. 

This attempt, during the lapse of centuries, must have been made 
many thousands of times, and always with the same unsuccessful 
result; and the idea of extracting it with a pincers or forceps suffi- 
ciently large to grasp the head, must also have presented itself for 
ages ; but how to apply the forceps ? A straight forceps could not 
grasp the head, it would slip off from the head as if it was wedge- 
shaped; while to make the forceps curved, so as to grasp the head, 
would make it. impossible to introduce it, since the forceps must first 
enter into the genital fissures, and then expand sufficiently to pass 
over the parietal protuberances so as to grasp the head when carried 
upwards far enough. It could not expand sufficiently to go over a 
head large enough to occupy with its own bulk the entire capacity of 
the excavation. Such, in fact, was the forceps of Palfyn, and such 
must have been the instrument spoken of by some of the Arabians. 
No forceps that could be got on to the undelivered head had been dis- 
covered; and in all cases, where the child could not be pushed back 
and turned, or where the- head became permanently arrested, the 



THE FORCEPS. 469 

medical people were obliged, either to let the mother and her offspring 
perish together, or they unscrupulously sacrificed the child, to insure 
the escape of its parent. Our ancestors consoled themselves with a 
quotation from Tertullian to the following effect: " Atquin et in ipso 
adhuc utero, infans trucidatur 7iecessarid crudelitate, quum in exitu 
obliquatus denegat partum, matricida qui moriturus ." Barely to look 
over some of the plates representing the obstetric instruments em- 
ployed previously to the discovery of the modern obstetric forceps, is 
sufficient to produce a shudder in any one familiar with the difficulties 
met w 7 ith in parturition ; and the griffin's claws, sharp crotchets and 
tire-tetes, which were the boast of their inventors in a barbarous age, 
serve but to set forth more signally, by comparison, the eminent use- 
fulness of the modern instrument, to which we are indebted for our 
own escape from the necessity of employing such means as were very 
familiar and commonplace with our predecessors. 

The great desideratum in Midwifery was a forceps that might seize 
the head and extract it, without inflicting a wound ; and we are in- 
debted for it to a Doctor Paul Chamberlen, who practised midwifery 
in England towards the close of the sixteenth century. He construct- 
ed, probably with his own hands, two curved pieces of iron, which, 
being introduced separately, were applied in succession to the left and 
right sides of the head, and then united by a pivot joint, by means of 
which the two separate pieces were converted into a pincers, or for- 
ceps, the handles of which crossed each other at the pivot or joint, 
and thus became capable of grasping and firmly holding the oval- 
shaped head of the child, while still contained in the womb or vagina. 
As the handles crossed each other, and were secured by the pivot, 
which passed through a drilled or morticed hole in the handles, it fol- 
lowed, that, when the extremities of the handles were pressed towards 
each other, the head was firmly grasped betwixt the blades or clams. 
The compressing force being duly applied, a sufficient degree of ex- 
tracting power enabled the Surgeon to draw the head forth from the 
passages, and the child was born without necessarily experiencing 
the smallest injury. 

This great discovery, the essential value of which is known only to 
medical men, would have entitled its author to the everlasting grati- 
tude of his fellow-creatures, had he not tarnished his fame by shame- 
fully making a secret of what ought to have been instantly promulgated 
for the general use of all who stood in need of its merciful interven- 
tion. But the spirit of the age, or a venal spirit of his own, induced 
him to confine his secret to his own breast, to be communicated, at 



470 THE FORCEPS. — PAUL CHAMBERLEN. 

length, to his sons, who were instructed in the mode of its use, and 
are supposed to have drawn large profits from the necessities of the 
unfortunate women who, knowing their superior skill, were compelled 
to seek for safety at their hands. 

Little is now known of these persons except their names; and they 
have deservedly sunk into the comparative oblivion which ought to 
overtake all those who, whether by accident or by the possession of 
genius, come into the enjoyment of facilities which ought to be the 
common property of humanity, but who, instead of divulging them 
and spreading their use and employment as far as the want of them 
extends, are induced by a vile thirst for gold to retain them within 
their own hands, and sometimes permit their secret to perish with 
them, rather than give it all the publicity and currency which its im- 
portance entitles it to. Such is the spirit of quackery or empiricism, 
under whatever guise or in whatever art, and the fate of the Cham- 
berlens, whose memory is almost forgotten already, is but a just retri- 
bution for their inhuman reservation of their valuable secret. 

There is a very curious and interesting case related by Mauriceau, 
in which he informs us that Hugh Chamberlen, one of the sons of the 
inventor, went to Paris in 1609, with a view to sell his secret to the 
Government, and while there, boasted in the most confident manner 
of his ability to deliver any woman, in any labor, no matter how diffi- 
cult, in half-a-quarter of an hour. It happened, at this time, that a 
woman, with a deformed pelvis, fell into labor, who, after vain attempts 
to deliver her, was put into Chamberlen's hands. He undertook the 
management of the case with the utmost boldness, but, after a cruel 
perseverance of three hours, was compelled, through sheer fatigue and 
exhaustion, to give it over, confessing his inability to effect the delivery. 
The poor woman perished shortly after his retreat, and her body being 
examined, it was found Jhat he had lacerated the womb and vagina 
in various places, with the points of the forceps. Mauriceau was so 
disgusted with the issue of this affair that he afterwards inveterately 
opposed the use of such instruments ; while Chamberlen immediately 
returned to England, and drew very large receipts from the practice of 
midwifery in London. Mauriceau's account of this transaction is so 
quaint and original that I think I ought to lay it before my readers as 
nearly as I can in his own style. The caption of the article is as fol- 
lows: 

" Of a woman who died with her child in the womb, which could 
not be removed thence by an English physician that had undertaken 
to deliver her. 



THE FORCEPS. HUGH CHAMBERLEN. 471 

"On the 19th day of August, 1670, I saw a little woman aged 
thirty-eight years, who had been in labor of her first child for eight 
days, the waters having escaped the first day that she found herself 
sick, without any dilatation scarcely of the womb. Having remained 
in this state until the fourth day, I was sent for to give my opinion 
to the midwife, whom I advised to have her bled; and in case the 
bleeding should not produce the good effect we might hope from it, 
then to make her take two drachms of infusion of senna, to bring on 
the pains, which was done the day following, and succeeded pretty 
well, this remedy having excited pains which dilated the uterus as 
much as it was possible. Notwithstanding this, she could not bring 
forth, and her child, which came with the head presenting, but with 
the face upwards, remained alw 7 ays in the same place without being 
able to advance to the passage, which this woman, who was very 
small, had so narrow, and the bones that form it so straitened and 
near to one another, and the bone of the crupper so curved forwards, 
that it was entirely impossible for me to introduce my hand to deliver 
her, though I have a rather small one, when I was sent for to succor 
her, three days after the first time that I had seen her. So having 
essayed ineffectually, it was impossible for me to succeed, not being 
able to introduce my hand but with great effort, in consequence of 
the narrowness of the passage between the bones, and having intro- 
duced it, finding it so cramped, that it was impossible to move even 
a finger, or to advance it far enough to be able to conduct a crotchet 
with safety, in order to draw away the child, that according to ap- 
pearances had been dead for four days: which having attempted, I 
declared the impossibility of delivering this woman to all the assist- 
ants, who, being well persuaded of this, begged me to take the child 
from the belly by the Caesarean operation ; this, how T ever, I did not 
choose to undertake, knowing that it was always most certainly fatal 
to the mother. But after I had left the woman in this state, not being 
able to succor her, as I should have done any other w r ith a more natu- 
ral formation of body, there came immediately an English physician, 
named Chamberlen, who was then at Paris, and who from father 
to son made a regular profession of midwifery in England, in the 
town of London; w^here he has acquired, since that time, the highest 
degree of reputation in that art. This physician, seeing the woman 
in the state that I have just described, and hearing that I had been 
quite unable to deliver her, seemed much astonished that I had not 
succeeded, w r hom he declared and asserted to be the most expert man 
of my profession in Paris ; notwithstanding which, he promised at 



472 THE FORCEPS. — HUGH CHAMBERLEN. 

once to deliver her, very surely in less than half-a-quarter of an hour, 
no matter what difficulty he might find. To do this, he set himself 
right to work, and instead of half-a-quarter of an hour, he labored 
for more than three entire hours, without so much as stopping to take 
breath. But having exhausted to no purpose all his strength, as well as 
his patience, he was obliged to give it up, and declare, as I had already 
done, that it was impossible to succeed. This poor woman died un- 
delivered twenty-four hours after the extreme violence he had done 
her; and upon the examination that I made of her body, by perform- 
ing the Caesarean operation after her death, which I had not wished 
to do, as I had already said, during her life, I found the child and 
other organs disposed as I described above, and the womb all torn 
and pierced in several places, by the instruments that the physician 
blindly made use of without the guide of his hand, which, being as 
large again as mine, he had of course been unable to introduce far 
enough to serve as a guard to the surrounding parts. Yet this phy- 
sician had come from England to France six months before, in hopes 
of making his fortune, sounding abroad the report that he had a secret 
altogether unknown for deliveries of that kind, boasting loudly that he 
could deliver the most desperate and abandoned cases in less than 
half-a-quarter of an hour; and he had even proposed to Monsieur, 
the first physician of the king, that if he would give him ten thousand 
crowns as a recompense, he would divulge his pretended secret. But 
the single experience of this disastrous case so disgusted him with 
.the country, that he returned a few days afterwards to England ; see- 
ing well that there were at Paris more experienced persons in the art 
of midwifery than himself. But before leaving for London, he came 
to my house, to compliment me on my Book of Obstetrics, that I had 
published two years before ; and told me then, that he had never met 
so difficult an operation as the delivery of this woman, in which he 
had been able to effect nothing, and complimented me because I had 
been unwilling to undertake it so inconsiderately as he had done. I 
returned his compliment in the proper way, and gave him to under- 
stand that he had much deceived himself in supposing that he should 
find it as easy to deliver women in Paris as in London, to which place 
he returned the next day, carrying with him a copy of my book, which 
he caused to be printed, after translating it into English, in the year 
1672, since which translation he has acquired so high a degree of 
reputation in the art of midwifery in the town of London, as to gain 
thirty thousand livres per annum, which he does at the present day, 
according to what was told me a short time since by some persons of 



THE FORCEPS. HUGH CHAMBERLEN. 473 

my acquaintance. Should he some day read this case, after I shall 
have made it public, and should he be as sincere as I am, I believe 
he will confess that I have reported it with all the precision demanded 
by the most faithful veracity, of which he may very readily judge. 
The extraordinary difficulty that occurred in this case caused me to 
invent an instrument to which I gave the name Tire-tete, from its 
use, which is incomparably more commodious and sure than the 
crotchets. 

"If I had had such an instrument at that time, I am sure I could 
have saved the life of that poor woman. I have had a picture made 
of it in my book on Midwifery, where I have taught precisely the pro- 
per mode of applying it." 

Inasmuch as Chamberlen's preface to Mauriceau's work on the dis- 
eases of women with child and in child bed, is exceedingly rare — 
and particularly so in the United States — notwithstanding my detesta- 
tion before expressed of his wicked conduct in concealing his inven- 
tion, I deem it proper to republish in this work his address to the 
readers of his copy of Mauriceau. It is but a proper contribution to 
the literary history of Midwifery, which I am sure that my readers 
will not be sorry to possess. The following are his words : — 

" Having long observed the great want of necessary directions 
how to govern women with child, and in child bed, and also how 
new-born babes should be well ordered, I designed a small manual 
to that purpose; but meeting some time after in France with this 
treatise of Mauriceau, (which, in my opinion, far exceeds all former 
authors, especially Culpeper, Sharp, Speculum Matricis, Sermon, &c, 
being less erroneous, and enriched with divers new observations,) I 
changed my resolution into that of translating him; whom I need not 
much commend, because he is fortified with the approbation of the 
wardens of the Chirurgeons Company of Paris. 

" His anatomy was in the first edition omitted, but is in this ; which, 
with the book, I have carefully rendered into English, for the benefit 
of our midwives; of whom many may yet very well admit of an ad- 
ditional knowledge. The principal thing worthy their observation in 
this book, is, accurately to discover what is properly their work, and 
w T hen it is necessary to send for advice and assistance, that so, many 
women and children may be preserved that now perish for want of 
seasonable help. My author makes out the breaking of the right 
w T aters, for the proper season of a natural delivery, and whenever a 
child is not born then, or soon after, nature is so much short of per- 
forming her office. This is certainly a great truth; and all wrong 



474 THE FORCEPS. HUGH CHAMBERLEN. 

births should never be longer delayed : and for the most part floodings 
and convulsions not so long, lest the woman lose her life before ever 
the water breaks ; but if no dangerous accident intervene, in a right 
labor, one may lengthen out their expectation to twelve hours after; 
and though some may have been happily delivered twenty-four hours, 
or two days after, yet I should not advise any to run that hazard, pro- 
vided they can have an expert artist to deliver them, without destroy- 
ing the child; because many have perished in that case; and it is 
not prudent to venture, where but one of many escapes. For the 
longer the labor continues after the breaking of the waters, the weak- 
er both woman and child grow, and the drier her body, which renders 
the birth more difficult ; and 'tis ever good taking time by the fore- 
top. 

"And that midwife's skill is certainly the greatest, and she de- 
serves most commendation, who can soonest discover the success of 
the labor, and accordingly either wait with patience, or timely send 
for advice and help. Nor can it be so great a discredit to a midwife 
(let some of them imagine what they please) to have a woman or 
child saved by a man's assistance, as to suffer either to die under her 
own hand, although delivered. For, that midwife mistakes her office 
that thinks she hath performed it, by only laying the women ; because 
her principal duty is to take care that she and her child be well, with 
safety and convenient speed, parted ; and if this be impossible for her 
and feasible by another, it will justify her better to waive her imagi- 
nary reputation, and to send for help to save the woman and child, 
than to let any perish, when possible to be prevented; as in the case 
of my author's sister, and in the twentieth chapter of the first book. 
Yet, in countries and places where help and good advice is not season- 
ably to be had, midwives are compelled to do their best, as God shall 
enable them ; which dangerous and uncertain trials it doth not become 
them to put in practice upon women, where no timely assistance need 
be wanting. Most wrong births, with or without pain ; all floodings 
with clods, though little or no pain, whether at full time or not ; all 
convulsions, and many first labors; and some others, though the child 
be right, if little or no pain, after the breaking of the waters, and the 
child's not following them in some six or ten hours after, require the 
good advice of, and, peradventure, speedy delivery by expert physi- 
cians in this practice ; for though a few may escape in these cases, 
yet the far greater number perish, if not aided by them. Let me 
therefore advise the good women, not so readily to blame those mid- 
wives who are not backward, in dangerous cases, to desire advice, 



THE FORCEPS. HUGH .CHAMBERLEN. 475 

lest it cost them dear, by discouraging, and forcing them to presume 
beyond their knowledge or strength, especially when too many are 
over-confident. 

" Those few things wherein I dissent from my author, if of danger- 
ous consequence, are noted in the margin ; if not, are left to the dis- 
cretion of the reader. 

"I confess he is often too prolix ; a fault which the French much 
affect ; however, I chose rather to translate him according to his own 
style, than contract him ; and also to leave unaltered some things not 
very w T ell expressed, being of small moment. I find also he distin- 
guishes not between the w^ords plaister and ointment, but uses them 
promiscuously one for the other. 

"In the seventeenth chapter of the second book, my author justifies 
the fastening hooks in the head of a child that comes right, and yet 
because of some difficulty or disproportion cannot pass; which I con- 
fess has been, and is yet the practice of the most expert artists in 
midwifery, not only in England, but throughout Europe, and has much 
caused the report, that where a man comes, one or both must neces- 
sarily die ; and is the reason of forbearing to send, till the child is 
dead, or the mother dying. But I can neither approve of that prac- 
tice nor those delays ; because my father, brothers, and myself [though 
none else in Europe as I know] have, by God's blessing, and our in- 
dustry, attained to, and long practiced a way to deliver women in this 
case, without any prejudice to them or their infants ; though all others 
(being obliged, for want of such an expedient, to use the common 
way) do, and must endanger, if not destroy one or both with hooks. 
By this manual operation a labor may be dispatched (on the least 
difficulty), with fewer pains, and sooner, to the great advantage, and 
without danger, both of women and child. If therefore the use of 
hooks by physicians and chirurgeons be condemned (without thereto 
necessitated through some monstrous birth), we can much less approve 
of a midwife's using them, as some here in England boast they do; 
which rash presumption, in France, would call them in question for 
their lives. 

" In the fifteenth chapter of this book, my author proposes the con- 
veying sharp instruments into the womb, to extract a head, which is 
a dangerous operation, and may be much better done by our fore- 
mentioned art, as also the inconvenience and hazard of a child dying 
thereby prevented, which he supposes in the twenty-seventh chapter 
of this second book. 

" I will now take leave to offer an apology for not publishing the 



476 THE CHAMBERLEN FORCEPS. 

secret I mention we have to extract children without hooks, where 
other artists use them, viz., there being my father and two brothers 
living, that practise this art, I cannot esteem it my own to dispose of, 
nor publish it without injury to them ; and think I have not been un- 
serviceable to my own country, although I do but inform them that the 
fore-mentioned three persons of our family, and myself, can serve 
them in these extremities, with greater safety than others. 

"I design not this work to encourage any to practice by it, who 
were not bred up to it; for it will hardly make a midwife, though it 
may easily mend a bad one. Notwithstanding, I recommend it to the 
perusal of all such women as are careful of their own and their friends' 
safeties, there being many things in it worth their noting: and design- 
ing it chiefly for the female sex, I have not troubled myself to oppose 
or comment upon any physical or philosophical position my author 
proposes. I hope no good midwives will blame me or my author for 
reprehending the faults of bad ones, who are only aimed at, and ad- 
monished in this work ; and I am confident none but the guilty will 
be concerned, and take it to themselves, which I desire they may, 
and amend. Farewell. 

"Hugh Chamberlen." 

The father of the above-mentioned Hugh was Dr. Paul Chamberlen, 
who had also for his son Dr. Peter Chamberlen, the one of which Hugh 
speaks in the preface to his translation of Mauriceau. There must 
have been another, since Hugh Chamberlen, in his preface above, 
speaks of his father, his brothers, and himself. The name of one of 
the brothers appears, therefore, to be lost. 

There are now in England specimens of the Chamberlen forceps, 
which have been recently discovered in an old box, concealed beneath 
the floor of a country house formerly owned by the Chamberlens, at 
"Woodham, Mortimer Hall, in Essex, England. They have been de- 
scribed by Mr. Causardine in J\Ied. Chir. Trans., ix. 183, into whose 
possession they came, and who had the good sense to present them to 
the Museum of the Royal College of Surgeons, London. There is the 
greatest reason to suppose that these specimens are instruments made 
by the Chamberlens themselves, and that the collection shows their 
progress in the invention, improving the apparatus at each successive 
attempt, until in one of the instruments they have succeeded in ob- 
taining a really valuable form. 

Being in London, in May 1845, I was greatly obliged by the kind 
assistance of Prof. Ed. W. Murphy, of University College, who not 



THE CHAMBERLEN FORCEPS. 



477 



only procured permission, but caused Mr. Coxeter, the cutler, to make 
fac-similes of the Chamberlen instruments for me, of which I here 
present faithful drawings. These drawings are five in number. 

Fig. 110 is an extremely w r ell-formed vectis, with a blunt crotchet 
at the end of the handle; the opening or fenestra is well represented 



Fig. 110. 




^> 



in the drawing, which is from my camera lucida. The figure cannot 
represent the head curve of this vectis, which is faulty in consequence 
of the slightness of that curve ; still it is an instrument of which one 
might make a fortunate use in a case of labor requiring nothing more 
than the vectis. The form of the hook at the other end of the handle, 
and the sharpness of its point, though they may perhaps entitle it to 
the character of the blunt hook, might leave one, upon a narrower 
examination, under the impression that the Chamberlens must have 
employed it rather as a sharp crotchet than as a modern blunt-hook. 

Fig. Ill represents, probably, the second attempt of the inventor 
to carry out his happy idea of the obstetric forceps ; it consists of two 

Fig. ill. 




separate pieces, both terminated by blunt-hooks at the handles; both 
possessing the old curve, and capable, therefore, of grasping the 
head, when once applied to it while lying within the genital passages. 
I say separate pieces, since the two pieces may be taken apart by 
unscrewing the pivot, which in the figure is seen passing through the 
lock. The right hand branch was forged out of one piece of iron, 
like the vectis at Fig. 110 ; but the left hand branch was a piece of 
thick iron wire carried out to the extremity of the clam, and then re- 



478 



THE CHAMBERLEN FORCEPS. 



turned towards the lock, where its extremity, being flattened, forms 
the square head for the reception of the screw-pivot. 

If this instrument, as I suppose, does really represent Chamberlen's 
second attempt at invention, it must be regarded as a remarkably 
successful effort; for, setting aside some imperfection in the amount 
of the old curve or head curve, it presents us with an apparatus, a 
true obstetrical forceps, of which the counterparts, being separately 
introduced and then locked by screwing in the pivot, may be so per- 
fectly adjusted upon the foetal cranium as to give the operator complete 
power over it. The fenestra is very good : the curves, however, are 
extremely faulty. Not so with the forceps, Fig. 112, which is in all 

Fig. 112. 




respects an admirable instrument as to the head curve, as may be 
seen by inspecting it in the drawing. The iron of which it was forged 
is, it is true, rather clumsy and heavy, but scarcely more to be con- 
demned, on that account, than the heavy Berlin forceps of Professor 
Siebold. It had no pivot joint, but the two compartments were fast- 
ened together by a strong flat braid, like that represented in the figure, 
which, being passed through the hole drilled in the lock of the instru- 
ment, and afterwards wrapped around the handles, would serve, after 
the adjustment of the blades upon the head, to hold it quite securely, 
and prevent even as much rocking motion as attends the use of the 
common English joint. 

Fig. 113 shows the last and most perfect form of the obstetric for- 



Fig. 113. 



<& 




<& 



THE CHAMBERLEN FORCEPS. 479 

ceps of the Chamberlens. It has what is now called the German lock, 
for the left-hand blade, or male blade, or lower blade, for these are 
synonymous terms, is provided with a fixed pivot to receive upon it 
the female or upper blade, as may be seen at Fig. 114, in which the 

Fig. 114. 




pivot is represented, the handle being terminated by the bending up- 
wards of the iron. 

I have never delivered a woman with one of these old Chamberlen 
instruments, and while I should much prefer an instrument made by 
a modern artist to either of these early specimens of the invention, I 
would not hesitate in any case, where the vertex was at the pubal 
arch, to employ either Fig. 112 or Fig. 113, if my Davis' forceps 
was not at hand. The instrument is scarcely inferior to the Haighton 
forceps in use in England at the present day. 

In 1733, Dr. Samuel Chapman published a " Treatise on the Art of 
Midwifery," &c, in which the forceps of the Chamberlens was given 
to the world, and from that time to the present day it has undergone 
many modifications of form and size, and mode of coaptation : almost 
every distinguished practitioner or writer selecting some particular 
fashion as most in accordance with his especial views. 

The instruments first employed had only one curve, that which applied 
itself to the head of the child in order to grasp it — and this is called 
the Old Curve; it ought to be called the Head Curve — so that the 
profile view of it represented a straight instrument. Such a straight 
instrument could be easily applied to the head whenever it had de- 
scended quite into the excavation, or whenever the ear could be 
touched by the point of a finger introduced into the vagina. But in 
all cases where the head was arrested while in the superior strait, a 
forceps possessing only the old or head curve could not well be em- 
ployed in its extraction, because the pelvis is itself curved, and hence 
when the points of the instrument should have mounted up sufficiently 
far to be on a level with or above the plane of the superior strait, the 
handles would necessarily press the edge of the perineum back too much 
towards the point of the coccyx. This pressure is both hazardous 
and painful, and endangers an early contusion of the perineum, or 



480 THE FORCEPS. — THE NEW CURVE. 

even its laceration. To effect such an adaptation would in all cases 
be found difficult, and in cases of rigid perineum, quite impossible. 

From the period of the publication of this invention by Dr. Samuel 
Chapman, up to the middle of the seventeenth century, several new 
forms, deserving perhaps to be called improvements, were offered to 
the profession. For a history of these various modifications, which 
it is not necessary for me to present in this work, I refer the Student 
to Dr. Mulder's Historia Literaria et Critica Forcipum et Vectium 
Obstetriciorum, in which he will find very accurate drawings of a 
great multitude of forms and dimensions of obstetrical instruments, 
down to a late period in the history of that apparatus. To look at 
Mulder's account is enough to excite a smile in the reader at the am- 
bition which proposes to build up a solid reputation rather by spoiling 
than by improving an implement already perhaps perfect. 

Professor Asdrubali, in his Trattato Generate di Ostetricia Teoretica 
e Prattica, vol. iii. p. 180, refers to Professor Manni's examination of 
the history and properties of the obstetric forceps, and he says: " Dopo 
questa correzione portata nel forcipe dagli Ostetrici di Londra e di 
Parigi circa la meta. del passato secolo, parea questo stromento giunto 
alia sua perfezione, ma lo spirito umano, sempre irrequieto piu per 
l'ambizione di distinguersi, che per giovare ai suoi simili, ne mise fuori 
una serie numerosa dei gia riprovati, e talvolta piu meschini di quelli." 
And he names the forceps of Loder, Galletti, Santarelli, Steidele, 
Johnson, Orms, Denman, Smith, Lowther, Osiander, Eckard, Stark, 
Bush, Siebold, Thenance, Du Bois, Mursinna, and Brunninghausen; 
and concludes that all these modifications do not exhibit any real 
improvement upon the forceps of Smellie and Levret. 

Dr. Smellie of London, and Dr. Levret of Paris, both conceived 
at about the same period, that is about the year 1750, the idea of giving 
to the blades a new curve on the edges, so as to adapt them to the 
axis of the superior as well as to that of the inferior strait; and ac- 
cordingly they produced the forceps with New Curves, which are al- 
most universally in use at the present day. Smellie used for common 
purposes his short straight forceps, fearing that too general and indis- 
criminate an employment of the long curved one might prove mis- 
chievous ; while Levret recommended his long and powerful instrument 
as being equally adapted to all cases proper for forceps operations. 
Smellie's instrument was united by the reciprocal notch called the 
English joint or lock, and Levret's was joined by a pivot and mortice, 
with a sliding plate, to secure it when united. Both the instruments 



THE FORCEPS. 481 

were provided with fenesters, but of an insufficient size to do much 
more than serve to render them lighter. 

The French forceps, somewhat modified by Pean, has great vogue 
in this country at the present time, under the denomination of the 
Baudelocque forceps. It is two inches longer than Levret's, and is 
constructed without the bead or raised line that runs round the inner 
or foetal face of the clams, and which, in his, was found inconveniently 
to cut or contuse the scalp of the infant. 

The obstetric forceps consists of two pieces or branches, a right 
and a left one, intended to be introduced separately between the sides 
of the head and the parts in which it is contained ; but alw T ays so ad- 
justed as to let the concave edge of the new curve look towards the 
front of the pelvis, to suit the curvature of which, it w T as originally 
contrived or invented. The part that is called the blade of clam ought 
always, if possible, to be applied on the side of the head, and not on 
the crown or occiput, and the extremity of the clam should reach up 
at least as far as the chin. Hence, in constructing a forceps, it should 
be always considered necessary to make the clam, or blade part, suf- 
ficiently long to reach at least from the child's vertex to its chin; a 
distance of about five inches in the uncompressed state of the head, 
but w T hich is much increased in some cases where the head is subjected 
to severe and long-continued compression in the passages. But while 
the head itself requires that the clams of the instrument should be 
five inches long, the different positions or situations in which the head 
is found at the time the forceps becomes necessary, demand that there 
should be given to the instrument length enough to embrace the head, 
whether it be high or low T in the pelvis; and that in introducing them, 
the lock or joint should not be carried within the orifice of the vagina. 

There must also be a handle of sufficient length and strength to 
admit of its being used with facility by the operator. The forceps 
therefore is divided into the blade or clams, the joint or lock, and the 
handles. The proportion of these several parts has been adjusted in 
various ways, according to the taste or judgment of the several makers 
of them. Dr. Smellie, who generally employed his short straight 
forceps, constructed them of the length of eleven inches, w 7 hile to his 
long curved forceps he gave a length of tw r elve and a half inches. 

The French or Baudelocque forceps, in very general use in this 
country, is a powerful instrument. The specimen that I have before 
me, and which is made by Messrs. Rorer, is exactly eighteen inches 
in length, the pivot or joint being very nearly midway from the end 
of the clams to the end of the handle. The ends of the clams ap- 
31 



482 DAVIS' FORCEPS. 

proach within three quarters of an inch when the handles are closed 
or pressed together, while the greatest distance between the clams is 
not quite two inches and a half. The blade or clam has an open 
fenester which is not quite an inch wide at its widest part, but which 
is six inches long, growing narrower as it approaches the lock, where 
it is not three-tenths of an inch in width. The lock or joint consists 
of a pivot in one branch, and a notch in the other. The pivot is fixed 
into its own blade by a screw, the top of which is a thumb piece, by 
means of which it may be screwed into or withdrawn from its place. 
The notch in the other blade is adjusted so as to receive the pivot into 
the left or outer side of the instrument, and the top of the notch, being 
countersunk, receives a conical shoulder at the bottom of the thumb 
piece of the screw, by which means it is made perfectly secure against 
any motion except that of opening and shutting the instrument. The 
end of each of the handles is curved outwards, so as to make a blunt 
hook, that may, upon occasion, serve all the purposes for which the 
blunt hook is used in midwifery. The weight of the specimen is two 
pounds and seven-eighths of an ounce. 

This powerful instrument, in skilful hands, may be made use of to 
overcome very great obstacles; but, in careless or unskilful applica- 
tion, may be the cause of great mischief. It has been objected to 
by many prudent persons on account of the great weight of metal, 
and the severe pressure of the child's head, that may, almost uncon- 
sciously by the operator, be made with it. The late Dr. James very 
rarely used any other than a short-handled straight pair, called Haigh- 
ton's forceps: yet I have had occasion to witness the application, by 
him, of a pair modelled upon the plan of the Baudelocque forceps. 
It cannot be doubted that all the benefits of the small forceps may be 
obtained in the use of the large ones; and those who cannot con- 
veniently command a variety of instruments, would do well to fami- 
liarize themselves with that which I have above described. It has 
been well remarked by Baudelocque, that it is not so much the instru- 
ment that is to be looked to, as the hand that uses it. 

The most convenient forceps that I have ever employed, and that 
which I commonly make use of, is the instrument recommended by 
Professor Davis, of the University of London. 

The instrument now before me is the one described in Davis' 
Operative Midwifery, and was made by the late Mr. Botschan of Lon- 
don. It weighs ten ounces and three quarters, and is in length twelve 
inches ; its joint is the English joint, composed of a notch in the 



DAVIS' FORCEPS. 483 

upper surface of the left and in the lower surface of the right branch. 
When the handles are closed, the ends of the clams are seven-tenths 
of an inch apart, while the fenesters, at their widest part, are two and 
three-quarter inches asunder. The broadest part of the fenester is 
equal to two inches, and its whole length five inches. From the ex- 
tremities of the handles to the lock or point where the branches cross, 
is four and a quarter inches. After the branches are crossed, they do 
not divaricate, but proceed in parallel lines one inch and a quarter: 
hence, if a foetal head be ever so considerably elongated by the pressure 
of the parts, the clams are sufficiently capacious to contain it, being 
seven inches long. In this instrument, such are the width and length 
of the fenestra?, a large part of the parietal protuberances jut out 
through them w T hen they are fixed on the head. Indeed, the foetal 
head, when held within the grasp of this instrument, if it be properly 
adjusted, can hardly sustain any injury from it, so admirably is it 
modelled upon the curves of the cranium. 

I have several times delivered from the superior strait with Davis' 
forceps, an operation for which it is peculiarly well adapted by the 
boldness of the new curve, particularly upon its convex or inferior 
edge. I am quite free to confess my preference for this over all 
other instruments for the safe delivery of the child, because, as I 
repeat, I think it almost out of the bounds of possibility to injure the 
foetus with it, provided it be perfectly well adjusted, and used with 
common discretion. I have not myself employed the German forceps 
of Siebold, because I have considered that the handles are very clumsy, 
and so widely separated, when the instrument is adjusted on the head, 
as to expose us to the hazard of compressing the cranium too violently. 
I have also thought the handles too much curved. But the author of 
the instrument is justly celebrated for his skill; and I am also aware 
that this is the instrument preferred and often used in our city by Dr. 
R. M. Huston, whose judgment and skill demand my highest respect. 
This gentleman, who is frequently called upon for consultation, has 
informed me that his success with Siebold's forceps, modified by him- 
self, causes him to esteem it above all others. It ought to be observed 
that Dr. Huston's forceps, although modelled upon that of Prof. Siebold, 
is very different from it in regard to its lightness and manuability, in 
consequence of the great length of the lever. This is, perhaps, a fault, 
if it be true, as I believe it to be, that the obstetric forceps is not a 
compressor, but only a tractor. Shorter handles, which lessen the 
power of the lever, diminish the hazards to which the child is exposed 



484 



HUSTONS FORCEPS. 



from the compressive action of the instrument, which in all cases per- 
haps is too fearfully great. Short handles do not prevent us from 
holding the child securely: with short handles it is possible to make 
traction to an extent that is dangerous. My specimen of Siebold's 
forceps, manufactured at Berlin, weighs twenty-seven ounces and a 
half, while the instrument of Dr. Huston is but twenty-one ounces in 
weight. 

Fig. 115 is a representation of this forceps modified from Siebold's, 
which I have taken from Huston's edition of Churchill's " Midwifery." 



Fig. 115. 




Upon looking along the convex edge of the new curve of Huston's 
forceps, it will be seen that the line is almost straight from a point 
a little beyond the posterior terminus of the fenestral opening, to the 
handle, so that the instrument is more seemingly than really curved— 
for the instrument, strictly speaking, is the clams. The clams are 
not very much bent, especially the concave edge of the new curve. 

I subjoin here a drawing, Fig. 116, taken in the camera lucida, of 
my Davis' forceps made by Botschan, applied to the head of a child. 
It will be seen by inspection of the concave edge of the new curve 



DAVIS' FORCEPS. 



485 



that that edge is not very much bent, while the convex edge of the 
curve represents almost the quadrant of a circle ; and as the convex 
edge turns down to join the handle, which springs mainly from the 
concave edge, and is continuous therewith, it follows that when the 
instrument is introduced into the cavity of the pelvis, it rests easily 
therein, because it does not strain back the anterior edge of the peri- 
neum towards the anus, and even towards the point of the coccyx, 
as must happen when the head is seized high up in the pelvis with 
any other instrument. The edge of the perineum, in using this 
instrument, comes forward almost as far as the line which is con- 
tinuous with the concave edge of the curve. The great advantage 
attending the use of Davis' 
forceps, is found in its light- 
ness, weighing, as I said, ten 
ounces and three quarters; in 
the shortness of its handles, 
which, while they afford all 
the requisite purchase for 
making even the most pow- 
erful and dangerous traction, 
yet from the shortness of the 
lever, serve to guard the child 
against the mischiefs of com- 
pression. 

I reiterate the expression of 
my opinion that the obstetric 
forceps was never designed to 
act as a compressor, but only 
as a tractor. Dr. Davis' for- 
ceps is forged in such fashion 
as that its interior face is per- 
fectly adapted to the rotundity of those parts of the head which it 
touches; and the fenestras are so vast as to permit considerable por- 
tions of the parietal protuberances to project as segments of curves 
outside and beyond the fenestral openings. It would also be true to 
say that the instrument, when accurately adjusted upon the sides of 
the cranium, scarcely touches the maternal tissues within the pelvis. 
The exterior curves are also arranged so accurately that the tissues 
of the mother can never touch the edges of them ; so that they cannot 
be cut by them, the surfaces of contact being everywhere broad and 




486 

gently rounded. The admirable form of the old curve or head-curve 
enables the instrument to touch very large portions of the cranial 
surfaces, pressing them equably, and not unequably: so much so 
indeed, that when the instrument is accurately applied, it would be 
a very difficult matter to do with it the least injury to the fetus, 
since it can scarcely slide. I prefer it for ordinary cases to all the 
other instruments. 

Each blade of this forceps is provided with a supplementary coun- 
terpart much narrower than the principal blades, which may often 
be usefully resorted to in cases where, after easily adjusting the first 
blade, the apposition of the second blade is found to be difficult, dan- 
gerous, or impossible, in consequence of that portion of the head which 
the blade ought to cover, being driven or jammed with violence against 
the bony side of the pelvis. Under such circumstances, a narrow 
blade might admit of adjustment, whereas a broad one could by no 
means be with safety applied. 

I desire the Student to have a proper idea of the meaning and in- 
tention of the accoucheur in using the obstetric forceps. His course 
as a practitioner will take its color much from the impressions he 
receives concerning the nature and design of this valuable instrument. 
If I were possessed of such place and reputation as might give to my 
opinion any character of authority, I do not know in what manner I 
could exercise such authority more favorably to the interests of hu- 
manity, in this particular line, than by establishing the doctrine that 
the obstetric forceps is the child's instrument; that 
the perforator, the crotchet, and the embryotomy for- 
ceps, are instruments for the mother; and that the 
Caesarian operation is an operation to be performed 
for the benefit of the parturient woman. 

If a woman in labor is in a situation demanding immediate delivery 
by instrumental means, and that without any reference to the claims 
or interests of the child, it is clear that to lessen the volume of the 
cranium by perforation, and to extract it with the crotchet or with my 
embryotomy forceps, is the safest as well as the swiftest method that 
can be employed; and every accoucheur would prefer this method in 
a case exhibiting undeniable proofs of the death of the fetus. Hence 
I repeat that the obstetric forceps is designed to save the child, and 
that the relief which it gives to the mother is but an appurtenant to it. 

It is true that in the conduct of a labor, the accoucheur shall often 
come to the conclusion to deliver with the forceps on account of some 
excessive pain, inability, or danger, to which his patient is exposed ; 



487 

and this in cases where he would not adopt such a resolution from 
views relative to the safety of the child alone. 

In this sense, then, the Student might reply that the forceps is the 
mother's instrument ; to which I answer, nay, but it is the child's in- 
strument ; and I select it for my operation because it makes the child 
safe, which could not be were I to use the mother's instruments — to 
wit, the perforator and the embryotomy forceps. I dare not to use 
the mother's instruments in contravention of the rights of the child, 
but I may with the child's instrument relieve the mother, and save 
her, while I do it no injury. 

If the Student should take his impressions of duty from studying 
the English books of midwifery, he w r ill go into the world believing 
that the obstetric forceps is the mother's instrument, and he will use 
it for her, and for her alone; whereas, should he adopt the views above 
set forth, and w T hich I deem to be perfectly sound and wholesome, 
he will enter upon his career feeling and knowing that he possesses 
an apparatus with which to rescue the child when in danger ; and he 
will employ this instrument as often from indications relative solely 
to the child, as from indications relative solely to the mother. 

The obstetric forceps is designed to be applied only to the cranium 
of the child. It should never be applied to the pelvic extremity of 
the foetal ovoid. 

The blades are to be applied to the sides of the head, the extremities 
of them passing up nearly as far as the chin. See again Fig. 116. 
They may be applied to the head in occipitoanterior and in occipito- 
posterior positions of it, and also in the transverse positions which it 
sometimes assumes. They may also be applied to the head in face 
presentations, whether the chin be to the pubis or to the sacrum; and 
their consummate conservatism must be frequently appealed to, for 
the succor of the child, in those pelvic presentations in which the head 
cannot be extricated by the hand alone. 

When properly adjusted in a suitable case, they give to the surgeon 
control at will over the progress of the labor. 

I have said that the forceps is not a compressor, but merely a tractor. 
I might have said, that w 7 hile it is a tractor, it is also a double lever. 

In order to get a good idea of the lever-like action of the forceps, 
let the Student endeavor to deliver the foetus on the machine ; and, for 
this purpose, let him employ a Baudelocque or French forceps. Hav- 
ing grasped the head, let him take hold of the blunt hook of the left 
hand branch, and pull by that alone ; and, as he pulls, very gently, 
let him move the hook towards the left side ; and having carried it far 



488 FORCEPS NOT A COMPRESSOR. 

enough over in that direction, let him take hold of the blunt hook of 
the right hand branch, and pulling gently, or even by merely holding 
on enough to keep the clam of that branch from sinking into the pel- 
vis, if he carries the handle over to the right side, he will find what 
is meant by, and what is the great and efficacious power of the lever- 
like operation of the forceps, when moved, from handle to handle; for, 
as he carries the said hook to the right, the blade of the other half of 
the forceps will be seen to emerge from the pelvis ; and so, by alter- 
nating the lever-like motions, he will at last find that the forceps is 
withdrawn wholly from the pelvis, bringing away in its jaws the head 
of the young child unhurt by compression. 

The compressive action of the instrument is not needed, further 
than to cause it to hold the head firmly and steadily, while the lever 
or lateral, or the extracting or vertical power is applied through it. 
It is never applied to the foetus in breech or footling cases, until all 
parts of the child save the head, are born, for the delivery of which, 
under such circumstances, it is frequently required ; nor can it ever 
be required in those presentations which are manageable by the hand, 
the noose, or the blunt hook. 

One of the most dangerous errors relative to the forceps that a Stu- 
dent could take up, would be the opinion that the forceps is, in its 
very design, a compressive instrument: it is not so; the forceps is not 
a pincers, it is an extractor — it is a real tire-tete; and I think it ought 
to be established as a principle in obstetrics, that where there is not 
space enough for the descent of the head without the forceps, there 
cannot be produced a due proportion by merely squeezing the head 
down to the required dimensions by such an instrument. Lest, how- 
ever, I might by the above give a wrong impression of my views, it is 
needful that I should state, that a head, by long pressure of the pains, 
may be so moulded and reduced in diameter as to be squeezed through 
a pelvis smaller than the head was at the commencement of the tra- 
vail: whenever, therefore, the pains cease, or are insufficient to reduce 
it, the forceps, used as an extractor, may assist to that end; they 
should never squeeze it merely to compress and diminish its dimen- 
sions ; they should always embrace it firmly enough to hold on and 
draw it down, so that the passages may mould it as it descends. 

The celebrated Baudelocque, in order to learn, by inspection, the 
effects of direct pressure by the forceps, procured nine still-born chil- 
dren, and by moulding their heads in the hand restored them to the 
shape of the uncompressed head. He also procured three forceps of 
the very best quality, and as nearly alike as possible : he then applied 



FORCEPS NOT A COMPRESSOR. 489 

the instruments over the parietal protuberances, and squeezed the 
heads until the handles were brought into contact, and tied firmly 
with a string, so that each head might be accurately measured while 
under the compression, and then compared with its dimensions before 
the instruments were applied. Such was the force employed in bring- 
ing the handles into contact, that the instruments, though very choice 
ones, were all spoiled by the experiment. The instrument was sub- 
sequently applied so as to embrace the forehead and occiput, and the 
results ascertained. These excellent experiments, for the particulars 
of which I must refer the Student to VArt des Accouchemens, Part IV., 
chap. L, are commented on by Baudelocque as follows : 

"It may be concluded from these experiments: 1st, that the reduc- 
tion in size of the fcetal head, included in the clams of the forceps, 
differs according to the different degrees of firmness of the cranium 
at birth, and to the more or less complete closure of the sutures and 
fontanels. 2d, that this reduction cannot in any case be so consider- 
able as has by accoucheurs been supposed, and that it can with diffi- 
culty, and very rarely, exceed four or five lines, with the instrument 
acting upon the sides of the head. 3d, that the degree of reduction 
should never be estimated from the distance remaining between the 
ends of the handles when they are pressed together in the act of de- 
livering the head, nor from the amount of force employed to bring 
them towards each other. 4th, and lastly, that the diameters which 
cross the compressed one, far from increasing in proportion to the 
diminution of the compressed one, do not in general augment to the 
extent of a quarter of a line, and in fact are sometimes even lessened." 

The above-mentioned results, procured by so distinguished a writer 
as Baudelocque, ought to suffice for removing any lingering disposition 
we might have to regard the forceps as a compressing instrument, and 
we should then be fully on our guard against the propensity to use it 
for such an object; but let it be considered that the head does not fill 
up the pelvis as a nail fills up the hole into which it is driven, but 
that it is always caught and arrested by two or perhaps four points on 
which it is impelled, and we shall see that if we do use it to squeeze 
and reduce the size of the head, we shall only reduce those diameters 
that are already small enough, and augment those that are already too 
large, for it cannot be adjusted on the points that are in such close 
contact as to constitute a real arrest. The most proper view to take 
of the instrument is, that it is a substitute for proper labor pain, sup- 
plying the want of expulsive force when wholly absent, or aiding it 
when its force is insufficient to effect the delivery of the woman. Im- 



490 TO USE THE FORCEPS. 

possibilities are not to be expected from it; yet in all those cases 
where it is inapplicable, we are compelled to resort to other measures 
of a far less pleasant character. 

It is common to apply the forceps to the head only after it has got 
fairly into the excavation, and the nearer the head is to the external 
organs, the more easily may the instrument be adjusted upon it. Hence, 
whenever, in the management of a labor, we begin to perceive the 
signs that indicate the use of instruments, we often feel at liberty to 
wait until the presenting part can take an advantageous position, 
preferring to lose a little time, for the sake of acquiring greater facility 
and assurance of safety. Whenever the head has sunk so low as to 
get the vertex just under or behind the sub-pubal ligament, we ex- 
perience little difficulty in placing the two branches, successively in- 
troduced, into their proper positions, because the rotation is completed, 
and the bi-parietal diameter does not occupy the entire transverse 
dimension of the pelvis ; but when we have to apply it before rotation 
has taken place, there is frequently great difficulty in getting either 
the first or the second branch directly over the side of the head; but 
if we fail to adjust the branches accurately in opposition, we either 
cannot make them lock, or we lock them in such a way that the edge 
of the instrument contuses or even cuts the part of the scalp or cheek 
on which it rests, leaving a scar, or actually breaking the tender bones 
of the cranium, while the other edge cuts the womb or vagina, by its 
free and projecting curve. In fact, the forceps is designed for the sides 
of the head; and if, under the stress of circumstances, we are com- 
pelled to fix them in any other position, we shall always feel reluctant 
to do so, and look forward with a painful anxiety to the birth, in order 
to learn whether we have done the mischief we feared, but which we 
could not avoid. 

I ought also to mention, that cases occur in which the forceps is 
clearly indicated, but in which, upon trial, we can by no means apply 
them; the size and position of the head are such that we cannot by 
force or dexterity get the blade of the instrument betwixt it and the 
bony passages; in such a case proper skill and judgment ought to 
be employed, and then, when we cannot succeed, we must be con- 
tent to think that we cannot, and that no one else can ; and afterwards, 
we must resort to other means of relief. Further, we can sometimes 
adjust the forceps perfectly, but cannot effect the delivery, because 
the parts are too small. Here, also, we ought to suffer no feeling of 
mortification to vex us for want of success ; we should feel assured 
that we have exerted a sufficient degree of strength and dexterity, a 



TO USE THE FORCEPS. 491 

degree equal to what we ought to consider safe ; and being then con- 
vinced or satisfied that our duty has been, in so far, done, we lay aside 
the forceps to resort to ulterior measures. 

I have already said that the instrument is made for the head, to 
which alone it can be safely applied. It would crush or cut the breech, 
and the sides or the belly, if applied in breech presentations to those 
parts. 

The forceps cannot be applied unless the parts are favorably dis- 
posed ; for instance, the os uteri must be dilated and gone up over 
the head. The vagina and perineum also must be in such a condition 
that we need have no fear of lacerating any of those parts ; else, the 
operation is contra-indicated. 

A man shall hardly be justified who inserts his forceps within the 
os uteri. He must wait until the circle has risen above the parietal 
protuberance and can no more be felt. 

The pains must have been proved insufficient for their office, or the 
exigent demand for delivery, arising from hemorrhage, convulsion, or 
other states, must establish the indication. We should find ourselves 
inexcusable, if we should be led to use them where the pains are 
still of vast force, and where they fail of success on account of a 
preternatural resistance. If we judge that the power of the pains is 
already as great as the patient ought to bear, we ought not to apply 
the forceps, in order to add to the forces which are already perhaps 
of a dangerous degree of intensity. 

The motive for the use of the operation should be clearly under- 
stood as referring both to the mother and child ; to the mother alone; 
or to the child alone. The consent of responsible and interested 
persons should be obtained; the motives for the operation should, if 
possible, be clearly explained to the woman herself, and truthful, yet 
reasonable, promises should be made to provide for her safety and 
comfort, both of them requiring the operation to be done. If time 
permits, some professional friend should be invited to witness and 
sanction the operation. 

The position of the presentation should be well known ; and if 
needful, should be verified by the introduction of half the hand or the 
whole hand into the passage. The bladder and rectum should be 
evacuated, the latter by an enema, and the former by the catheter; 
the last precaution ought never to be neglected. 

The bed should be prepared by bringing the end or side of it quite 
to the end or side of the bed-stead, and then covering it with blankets 
and sheets of sufficient thickness to prevent the bed from being soiled. 



492 TO USE THE FORCEPS. 

Part of a sheet should reach down to the floor, on which some cloths 
ought to be placed, to receive the fluids that commonly escape during 
the process of delivery. 

The patient ought to be brought to the side or end of the bed, as 
the case may be, lying on her back, with the end of the sacrum pro- 
jecting far enough over the bed to admit of the most unrestrained 
access to the parts by the hand and the forceps. While lying in this 
manner the feet should rest on two chairs or on the laps of her assist- 
ants, sitting with their backs turned to the patient, and far enough 
from each other to allow the operator to stand or sit between them ; 
the patient always being covered with a light sheet or blanket, accord- 
ing to the temperature of the apartment. 

The instruments, at all seasons of the year, should be placed, be- 
fore using them, in a bowl of tepid water; and, when ready, they 
should be anointed with sweet oil, which adheres to them better than 
lard. 

Lastly, the parts should be freely anointed with lard. 

The forceps are differently applied, according as the head is differ- 
ently placed. 

If the vertex present, and rotation have taken place so as to bring 
the point of the head just below or behind the sub-pubal ligament, 
the left hand blade is to be taken in the left hand, and the fore and 
middle finger of the right hand should be passed upwards as far as 
conveniently can be done, betwixt the left ischium and the child's 
head, somewhat towards the posterior part of the pelvis, or towards 
the left sacro-iliac junction. The branch should be so held as to cross 
the right groin, in a direction from above, downwards and inwards, 
so as to let the point of the blade be near the vulva, in w T hich it is 
next gently and slowly introduced, allowing the concavity of the old 
curve to be in contact with the convexity of the head. In proportion 
as it immerges, the point is directed upwards towards the plane of the 
superior strait, the handle coming downwards as the introduction pro- 
ceeds, and care being taken to direct the point by the two fingers as 
far as they can reach. If any obstruction or difficulty is met with, 
let it be overcome by gentleness and dexterity, and not by force. 
For example, if the point comes in contact with the ear, that organ 
might very easily be lacerated by any rude force, and a great deal of 
caution ought to be observed in order to protect the child from such 
a maiming, and the medical attendant from such a disgrace. At 
length the blade is introduced sufficiently far to show that the point is 



TO USE THE FORCEPS. 493 

nearly even with the chin, and the old curve in contact with the side 
of the cranium, and face, and that it covers the ear. 

The end of the handle should now be depressed a little, and given 
in charge to one of the assistants, while the right hand branch is taken 
in the right hand, and the fore and middle fingers of the left hand 
are introduced into the vagina, on the other side, as in the case just 
described. The branch is laid across the left groin, looking from above 
downwards and inwards, and the point of the blade is passed into the 
vagina above the first branch. This one should also be at first directed 
towards the sacro-iliac junction of the right side, and elevated as it 
proceeds so as to be brought at last into exact opposition to the left 
hand branch. If any difficulty occurs in getting it forwards enough, 
the two left hand fingers that are guiding it will serve to slide it edge- 
ways into the proper position. The branches are now to be joined 
at the lock ; and the union of the branches is very easily to be effected 
if the opposition of the two counterparts is accurate. If the opposi- 
tion be inaccurate, the locking is impossible and ought not to be at- 
tempted by violent force. When locked, let the handles be brought 
near enough together to make sure that the head is firmly grasped, 
and then the instrument is to be withdrawn a little, in order to effect 
its more complete adaptation to the convex surface of the cranium, 
which it grasps or contains within its jaws. 

If the handles come not near enough into contact, that circumstance 
proves conclusively that the head is not properly seized ; and nothing 
further should be done until the error be corrected. If they gape 
more than an inch and a half at the ends, they are not adjusted upon 
the parietal bones ; but are obliquely fixed upon the frontal and occipi- 
tal regions. They ought to be a little more than an inch apart at the 
ends of the handles. 

"Whenever, during the process of introduction, a pain comes on, all 
action ought to be suspended until the pain has ceased. If this pre- 
caution be not observed, there is great danger of contusion, or lacera- 
tion by the blades of the instrument. 

It very frequently happens that the first or left-hand blade passes 
readily up to its proper position, and takes its place on the side of 
the head and face, without communicating the least disagreeable sen- 
sation to the patient, or causing the smallest embarrassment to the 
accoucheur; but, when he attempts to put the other blade into posi- 
tion, he either fails to insert it as deep as the other, or having done so, 
finds himself baffled in every effort to lock the joint. 



494 



TO USE THE FORCEPS. 



Fig. 117. 



The first blade has perhaps taken up so much space as to have 
thrust the head strongly over against the right side of the pelvis; 
leaving no passage betwixt it and the cranium along which to make 
the second blade glide. 

Upon the failure of discreet efforts, both of the counterparts should 
be gently withdrawn. Perhaps a new pain may now succeed in 
forcing the presenting part a little onwards: or, perhaps, after with- 
drawing the right-hand branch, the surgeon may succeed in using the 
left blade as a vectis so successfully as to bring the head into a bet- 
ter attitude; so that when the attempt to adjust the clams is renewed, 
no difficulty is found to remain. He shall often succeed in adjusting 
the right blade as a vectis, when he shall have withdrawn the left 
hand blade. 

When the two parts of the instrument are introduced far enough, 
they may be so imperfectly arranged that the concave edges of the 
new-curve may be almost in contact, while the convex edges divaricate 

very much, the ends of the handles 
having their flat surfaces obliquely 
placed, as in Figure 117. This 
could not happen except w T here the 
accoucheur has placed the instru- 
ment too near the occipital surface 
of the head, and too far from the 
bregmatic surface. An inexperienc- 
ed person is very apt in this case to 
suppose the very reverse, or that he 
has placed the convex edge of the 
new curve too far from the pubis 
and too near the sacrum : whereas 
it is really too near the pubal and 
too far from the sacral region of the 
excavation. 
If he makes this mistake, which, I repeat it, he will be apt to make, 
he would do well to remove the blade entirely, and give himself time 
to reflect anew upon the position of the child's head, and the relation 
of its right and left ears to the pelvic- walls. In this way, having 
mastered the topography of the case, he will be likely to succeed upon 
renewing his attempt. It w r ould be far wiser and far more charitable 
to do so than to make a barbarous and most unjustifiable endeavor to 
extract with forceps oblique and not in apposition, which they never 
can be when not in opposition. 




TO USE THE FORCEPS. 495 

Should he now succeed in making the adjustment, the handles will 
point parallel to the left abducted thigh in vertex labor in the first 
position, the head incompletely rotated ; or, vice versa, to the right thigh ; 
or, when rotation is complete and extension begun, they will point 
coincidently with the mesial line of the trunk. In proportion as the 
extension of the head makes greater progress, the handles rise upwards 
towards the woman's belly, for the head, bringing the forceps along 
with it in its descent, must pass out in coincidence with Carus' curve. 
The end of the handles in rising describes that same curve with a 
greater radius. 

The instrument being now adjusted over the sides of the child's 
head, as in Fig. 116, let care be taken, before proceeding, that no 
external part be caught or pinched by the lock or joint. This is as- 
certained by passing the fingers round and within the orifice of the 
vulva. In general, no attempt to extract should be made until pain 
or tenesmus comes on. When the woman is ready, therefore, let the 
handles be held in the left hand, while the middle finger of the right 
hand is placed in front of the joint or crossings, to assist in the ex- 
traction, while the index finger is to be pressed against the child's 
head, and always retained in contact therewith, during the extractive 
effort. The finger ought always, in this state, to touch the head; but 
if it leaves it, it is because the blades are slipping off, in which case 
traction should cease until they are adjusted again. While the finger 
remains in contact with the head, there is no slipping of the instrument. 
It is shameful to let the forceps slip off the head and fly from the 
vulva with a suddenness sufficient to lacerate the parts in the most 
frightful manner. 

The most successful mode of using the instrument at first, is to 
employ it as a lever, by moving it from handle to handle, exerting at 
the same time enough extractive force to prevent the opposite blade 
from plunging deeper into the parts, while we move the handles to 
the right, or to the left. 

Let me here repeat that, in exhibiting to my class a demonstration 
of the lever-like action of the forceps, after having adjusted the instru- 
ments on the head, in the phantome, I take hold of the blunt-hook 
of the left-hand branch, and leaving the other untouched, I draw that 
branch a little out, and at the same time carry it over towards the 
left thigh ; in this action the blade of the right-hand branch is found 
to be withdrawn considerably, bringing the head along with it. I 
next take hold of the blunt hook of the right branch, and drawing a 
little downwards, I carry it over towards the right thigh of the phan- 



496 TO USE THE FORCEPS. 

tome, by which the blade of the left branch is withdrawn in like 
degree, bringing the head, which it grasps, along with it; so that by- 
several successive movements of the sort the head is soon found to 
emerge completely from the vagina. One trial of this method on the 
phantome will show the Student how powerful is the action of the 
forceps used in this way. In this way, as one blade emerges, the 
other does not become immerged. 

In practice, all attempts at extraction ought to be made in conform- 
ity with the natural processes and dispositions or tendencies of the 
healthiest labor: there ought to be no hurry, no impatience, no tem- 
per exhibited by the operator. 

In natural labor there are intervals of rest; in artificial labor there 
ought also to be good intervals of rest ; which are required both for 
the physical relief, and the moral relief of the patient. Her mind is 
strained to the highest tension, by the mere thought that she is under 
the Operation, and the tissues against which we are dragging the child, 
yield better, for a minute or two of rest, repeated from time to time, 
as the case admits or demands. 

It should not be forgotten that the forceps embraces the head in a 
direction from the vertex to the chin ; nor that, when the head is 
evolved under the stress of the instrument, it ought to undergo the 
same mutations as it would if expelled by the natural pains. Hence, 
as the vertex emerges, and rises towards the front of the pubis, the 
ends of the handles must be permitted to rise along with it. They 
must never be prevented from taking the direction which the emerg- 
ence of the head naturally tends to give to them. In the last moments 
of the delivery of the head, during its extension, the inferior part of the 
occipital bone rests in contact with the mons veneris. If the forceps 
is still upon the head, in this situation its handles will almost touch 
the abdomen of the mother. 

A goodly proportion of the examples of forceps operations met with 
here, are, as I think, rendered necessary by rigidity of the soft parts, 
to overcome which, the expulsive faculties have been exhausted by 
vain efforts. Let it be well borne in mind that though the expulsive 
powers of the womb are enormously great, they sometimes fail of 
success because the vagina is not dilatable, or the perineum will not 
yield, or the labia will not suffer elongation; or all these obstacles may 
be in combined opposition to the delivery: remembering these things, 
we should not impatiently urge nature beyond her powers, lest we do 
injury where we are most solicitously endeavoring to do good. By 
rude and untemporizing exercise of strength, we incur very great 



TO USE THE FORCEPS. 497 

hazard of rupturing these organs, and of bringing ourselves into some 
discredit, and of maiming the patient most injuriously. It is very 
true that the forceps acts as a dilator by separating the sides of the 
vagina and of the vulva before the advancing head ; but, on this very 
account, and because it is so powerful a dilator, we are bound to ex- 
ercise the greatest prudence in the use of it. I have, in many in- 
stances, refrained from the use of the forceps, in cases where they 
were, on other grounds, strongly indicated, because I could appreciate 
the unreasonableness of any attempt suddenly to dilate the external 
organs, which I perceived to be far more frangible than dilatable. 

It not unfrequently happens, that, in cases where the head has 
suffered a long arrest, and the natural powers have proved incompetent 
to its effectual advancement, the application of the forceps, and very 
moderate tractions with the instrument, will put it in rapid motion, so 
as to leave no doubt of its speedy expulsion under the natural powers. 
In such cases I have been accustomed to remove the forceps, and allow 
the child to be born by the spontaneous exertions of the womb. I 
do this with the view of sparing pain to the mother, and under the 
conviction that the organs are less likely to suffer contusion, or lace- 
ration without, than with, the instrument. But it ought not to be done 
except under full conviction that the expulsive powers, thus set in 
renewed activity, will be successful, since it is very mortifying to 
withdraw them prematurely, and be obliged to reapply them. 

Inasmuch as we cannot exert any very considerable tractile force, 
without compressing the head with a severity proportioned to it, we 
should occasionally relax our hold on the handles, in order to let the 
blades cease from pressing the cranium. The effects of the pressure 
are rendered less dangerous for the child, by being occasionally inter- 
mitted. The same reasons are conclusive against the practice used 
by some persons, of tying the handles with a fillet, which makes it 
impossible to relax the grasp of the clams, without the trouble of 
untying the fillet every time such relaxation happens to be thought of. 

Extreme caution is required for conducting the last stages of the 
operation with safety. The perineum should be well supported with 
a napkin held by the operator, or an assistant; and the delivery of 
the head should be deliberate and slow, and the patient exhorted to 
lie as still as possible. In delivering a lady rather advanced in life, 
of her first child, I was using a moderately strong traction while the 
head was passing out. On a sudden she threw up the pelvis, which 
changed the line of movement of the head ; as I had the handles of 
the forceps pretty firmly grasped during the muscular efforts I was 
32 



498 FORCEPS. — NO ROTATION. 

making, I could not let go soon enough to prevent the head from 
lacerating the perineum very severely. I felt then, and still do feel 
confident, that the perineum w T ould not have been torn but for the very 
unexpected and violent movement of her pelvis. She recovered from 
the effects of the laceration in about three weeks. 

As soon as the head is delivered, the forceps are to be removed and 
handed to an assistant, while we take care to attend to the delivery 
of the shoulders, and finally, receive the child, which is to be done 
as in the most natural labor. 

A more difficult operation than that just described is the application 
of the forceps where rotation of the head has not taken place. 

The first, and one of the most important steps here, is to ascertain 
accurately — I say with absolute accuracy — the situation of the foetal 
head. If the finger can reach the posterior fontanel, w T e ought to be 
able to appreciate, from that point, the relative situation of all the 
other parts of the cranium. If any doubt, however, remains upon the 
mind, after an attempt to discover the truth by the employment of the 
finger alone, the whole, or one half of the hand should be introduced 
into the vagina, so that by grasping the cranium with several fingers, 
we may become positively sure that our diagnosis of the position is 
correct. We will suppose the examination to have resulted in ascer- 
taining that the vertex is in the first position, i. e. directed to the left 
and front side of the pelvis. 

The patient is to be placed upon the back, as in the other case, 
and the point of the left hand branch of the forceps, guided by two 
fingers of the right hand placed in the left posterior part of the vagina, 
is to be passed upwards in front of the left sacro-iliac symphysis. The 
end of the blade being conducted up to the child's chin, it will be 
found that the pivot of the blade will look upwards and to the left, 
and the handle will be inclined towards the left thigh of the patient. 
The blade being properly adjusted, an assistant should be put in 
charge of the instrument, while the right hand branch, guided by two 
fingers of the left hand, is next to be introduced into the right and 
lower part of the vagina, and gradually conducted forwards along the 
side of the head, to the right side of the chin, so as to cover the ear; 
the notch being just opposite to the pivot. If the blades should not 
be found opposite to each other, they will not lock ; they must be 
placed in opposition by bringing one of them more to the front of the 
pelvis, or pushing the other more towards the sacrum, and when they 
press upon the opposite sides of the head, there is no difficulty in 
uniting them. When the branches are locked, they are inclined to- 



FORCEPS. NO ROTATION. 499 

wards the left thigh of the mother, the pivot still looking upwards and 
to the left, and the handles having an appearance of awkwardness in 
this situation, which, to a tyro, communicates a feeling of doubt as to 
their being well placed. They look as if they were crooked, but this 
very awkwardness is. the best evidence of their being situated right. 

When ready to proceed with the extraction, advantage should be 
taken of the first pain, not to rotate the head by twisting the vertex 
to the right, but by moving the instrument from handle to handle, 
using at the same time a proper degree of traction. The rotation 
takes place as the head advances, and the vertex very soon comes 
under the pubic arch, without any particular effort being made to ro- 
tate it. As soon as the vertex reaches the pubis, the peculiarities of 
this application of the forceps cease, and the remaining steps of the 
operation proceed as in the first described case. 

The vertex may present in the second position, in which case the 
posterior fontanel is towards the right and front of the pelvis. Let the 
woman be placed as before: after introducing two fingers of the right 
hand into the left side of the vagina, the left hand branch of the for- 
ceps is to be conducted into it towards the fourchette, the point of the 
blade sweeping upwards towards the child's chin, covering part of the 
ear, and coming off at the vertex. The handle will look towards the 
right thigh, and the pivot will point upwards, and towards the right. 
The handle of the forceps should be very much depressed in this 
case, because, as the lock portion of the branch is inclined towards 
the right, it leaves scarcely space for the introduction of the female 
counterpart, which is to be introduced on that side ; but a considera- 
ble depression of the handle affords a more abundant space for that 
purpose. The branch, being correctly placed, is put in charge of an 
assistant, while the right hand blade, being guarded by the introduc- 
tion of two fingers, is passed into the vulva at its lower or back part, 
and its point turned upwards and towards the left, as the handle 
sweeps downwards and towards the right. The joint is brought into 
apposition and locked. 

As soon as a pain comes on, traction, combined with the lever-like 
action, must be instituted, and as the head descends, the mechanism 
of the pelvis compels the vertex to rotate towards the pubis, under 
the arch of which it soon begins to jut. This being effected, the 
peculiarities of the operation are removed, and its remaining conduct 
is to be fulfilled as before. 

In those cases in which the vertex, instead of coming to the arch, 



500 FORCEPS. — NO ROTATION. 

rotates backwards and falls into the hollow of the sacrum, the forceps 
will be more likely to be required, because the difficulties of expul- 
sion are greatly enhanced by the position. In this, as in all the occi- 
pitoanterior positions, the vertex must escape first, notwithstanding 
it be directed backwards towards the sacrum; but in order to do so, 
it must glide down the sacrum and coccyx, and along the perineum, 
after having distended it enormously, until the fourchette slides back- 
wards and upwards behind the occipital bone of the infant. In order 
to effect this, the occipito-mental diameter of the foetus must become 
parallel with the axis of the inferior strait, or at least it must become 
nearly so. Such, however, is the violence of the flexion required for 
that purpose, that much time is lost before it can be effected; and the 
woman is, in many of the instances, exhausted, and the pains gone, 
before it can be completed. 

The position is ascertained by feeling the large fontanel behind the 
pubis, or just within the arch, while the sagittal suture runs backward 
towards the sacrum. 

When it is found that the forceps will be required to extract the 
head, let the male branch, held in the left hand, be introduced into 
the back and lateral part of the vagina, and conducted towards the 
chin as far as possible, carrying the instrument up near the left sacro- 
iliac junction at first, and gradually bringing it forwards so as to apply 
it accurately to the side of the head. The oblique diameter of the 
head dips so much towards the sacrum, that it is impossible to embrace 
the head properly without depressing the handle very much, and 
thrusting the edge of the perineum very far back, which, though not 
a little painful, cannot be avoided ; otherwise the head will be grasped 
coincidently with its perpendicular and not its oblique diameter. The 
instrument being held in this way by an assistant, leaves a sufficient 
space on the right side of the vagina for the introduction of the female 
branch, which being adjusted and locked in the male branch, leaves 
the handles very much depressed. 

Having been well satisfied that none of the external parts are pinched 
at the lock, and that the head is firmly grasped, the first movement in 
extraction should be to raise the handles up a little, with a view to 
compel the chin to approach still nearer the breast, and in that way 
permit the vertex to glide down the sacrum and coccyx, assisting its 
descent by means of the lateral or lever action of the forceps; the 
intention of the operator should be to draw the vertex off the sacrum, 
perineum and fourchette, to let the head extend backwards on the 
outside of the pelvis. 



FORCEPS. — OCCIPITO-POSTERIOR POSITION. 501 

As the perineum must, in this labor, be enormously distended, it 
behoves that great care and patience should be exercised, lest it might 
give way. It should be well supported, and as soon as the vertex 
clears the edge of the perineum, the handles ought no more to be 
raised, but on the contrary depressed, in order to let the head extend 
backwards — a movement exactly the reverse of what takes place in 
the occipito-anterior position. The head being delivered, the shoulders 
rotate in the excavation, and the right or the left one comes to the 
pubic arch, so that the rest of the process is concluded as in a first or 
second position, except that the front parts of the child, instead of the 
back parts of it, come out towards the front of the pelvis, which makes 
no difference of any import. 

The application of the forceps for the occipito-posterior position, 
say the fourth or fifth, where rotation has not taken place, is more 
difficult than the one just above treated of. The blades are with much 
less facility applied, and indeed cannot take hold along the oblique 
diameter so completely as is to be desired; they rather seize the head 
along its vertical diameter at first, and are gradually brought into 
parallelism with the oblique one, as extraction proceeds. Reflection 
upon this circumstance is very needful, at the time of the operation, 
lest the infant's head be, by want thereof, contused and ground, and 
even cut by the blades. 

The introduction takes place as in a first or second position, the 
fourth corresponding to the first, and the fifth to the second. The 
handles must be well depressed in this case, and it will be allowable 
to make prudent efforts to rotate the vertex into the hollow of the sa- 
crum — it being always understood that, in such labors, all hope of 
bringing it to the pubis, has, after experiment, failed. 

The head is sometimes situated transversely, the vertex resting 
against one, and the forehead against the other, ischium. Let us sup- 
pose the vertex at the right ischium. It is intended to apply the male 
blade to the left side of the head, with the concave edge of the new 
curve looking towards the occiput. 

Let the left hand branch be therefore introduced into the left and 
posterior part of the vagina, and as the point enters more and more, 
the handle should be depressed, until the curve applies itself on the 
left side of the head in a direction from the vertex to the chin, or as 
nearly so as may be practicable. It should be understood, however, 
that the blade will scarcely apply itself in that direction, because the 
chin is not so near to the breast as it ought to be. When the blade 
is adjusted, its pivot looks to the right, and lies in a horizontal posi- 



502 FORCEPS. — TRANSVERSE HEAD. 

tion, while the handle juts out very obliquely towards the right thigh, 
which is much abducted. 

As the left hand branch projects towards the right, there will be 
some difficulty in finding room for the introduction of the right hand 
branch; yet t>e other can be temporarily pushed out of the way, so 
as to let the point enter at the inferior and right side of the orifice of 
the vagina. When the curve is applied to the convexity of the cra- 
nium, it must be pushed upwards, backwards, and towards the left, 
so that its point may approach the chin, and the notch be brought in 
apposition with the pivot, and so locked. The head being firmly 
held, may be moved in the direction from handle to handle, and mo- 
derately rotated, so as to dislodge it; and the tractions being soon com- 
menced, it is found to descend, the forceps rotating along with it, until 
the pivot turning to the left becomes vertical, and the fontanel appears 
at the arch. 

Now it appears, that in all the operations I have described, the male 
or inferior blade is to be first introduced, without doing which the 
female or upper blade cannot be introduced, without getting it below 
the inferior blade. There is one position of the head, however, in 
which it is proper to introduce the female blade first — and there is 
but one — which I shall proceed to treat of. The position to which I 
allude is that in which the vertex touches the left ischium, and the 
forehead the right ischium. 

It is clear that when the instrument has grasped the head in this 
position, the handles will project very much towards the left thigh, in 
abduction; but if we introduce the male blade first, inasmuch as its 
handle will project towards the left thigh, it will occupy all the space 
on that side, and hinder or prevent the insertion of the second branch, 
for there is no place for the handle to be depressed in. To avoid this 
difficulty, therefore, take the female or upper blade in the right hand, 
and introduce it into the posterior and right side of the vagina, con- 
ducting its point as near as may be to the chin, and over the face to 
the right side of the head behind the pubis, leaving the handle to pro- 
ject towards the left thigh. Next take the male blade into the right 
hand, and, turning the concave edge of the new curve downwards, 
insert the point into the right side of the vagina, below the female 
branch. Let the foetal face of the clam apply itself to the convexity 
of the head, and slide it onwards, and in proportion as it enters, 
make it sweep round the crown of the head towards the back of the 
pelvis. In effecting this, the handle comes gradually down as the 
clam gets on the left side of the cranium, and at last the lock is found 



FORCEPS. — FACE PRESENTATION. 503 

to be where it ought to be, namely, under the upper or female blade, 
■with which it is then locked. 

When we have ascertained that the head is properly held, or grasped, 
we may proceed, as before, to move and to attempt to rotate it, and 
then deliver as soon as the vertex emerges from beneath the symphy- 
sis pubis. 

Among the sixteen thousand four hundred and fourteen women 
delivered at the Dublin hospital, under charge of Dr. Collins, thirty- 
three had face presentations, and four of these had still-born children, 
which is a little less than twelve per cent, of mortality in this labor. 
I have said enough in my observations on Face Presentations, at 
page 327, et seq., to make it unnecessary for me to repeat anything 
here in relation to the difficulties of that sort of birth. It is merely 
proper for me to remark that the forceps, w T hen their use is indicated 
in this labor, must be applied to the sides of the head by carrying the 
points of the blades up to the vertex nearly. In those examples in 
w T hich the chin comes to the pubis, the handles need not be very much 
depressed ; but in those in which the forehead is at the pubis, the 
handles must be at first very strongly depressed, and as the case pro- 
ceeds, they must be strongly elevated, so as to get the chin down to 
the fourchette, over which it must slip, and then begin at once to 
approach the breast again, in the act of flexion. As soon as the chin 
is free, we allow the handles to descend again, while we continue the 
traction until the head is completely emerged. I shall take this oppor- 
tunity for stating, that I conceive it to be impossible to have a better 
instrument for this particular labor, than Davis' forceps, as made by 
Botschan, 35 Worship street, London. This instrument holds the 
head as in a basket, and is far less likely than any other with which 
I am acquainted, to bruise or in any way injure the child. Figures 
75 and 78 show very clearly the difference between a face case, in 
which the chin comes to the pubis, and one in which the forehead 
is there, and may well show the manner in which the head is to be 
taken hold of by the forceps. 

The head is said to be locked, whenever two opposite sides of it 
are caught by two opposite sides of the pelvis, and held so firmly 
there, that it can descend no lower, and either cannot, or cannot with- 
out great difficulty, be pushed upwards again into a freer or larger 
space. In general, when the head is thus locked, it is in its transverse 
or bi-parietal diameter, one parietal protuberance being held at the 
pubis, and the other at the projection of the sacrum. Supposing the 
pelvis to be only three and a half inches in its antero-posterior dia- 



504 FORCEPS. — LOCKED HEAD. 

meter, and the head to be three and three quarters in its smallest dia- 
meter, then it might happen, as it does in fact happen, that the cone 
of the head should be driven, by the force of the pains long continued, 
into the narrow pass, the delicate bones of the head giving way, and 
becoming indented under the pressure of the promontory of the sa- 
crum, and moving downwards until it becomes immovably fixed and 
held fast by the opposing points of the pubis and sacrum. This state 
would constitute what is called a locked head. Many evils result 
from this locking of the head. For example, the woman, after vain 
efforts and very great suffering, becomes feverish, and at length loses 
her pains altogether; or a state of constitutional irritation comes on, 
marked by a frequent, small pulse, coolness of the extremities, sunken 
or cadaverous appearance of the face, delirium, jactitation and vomit- 
ing, which, if not soon relieved, is followed by death, which hastens 
at rapid strides to end the strife. The pressure destroys the child; it 
also produces the death of the parts of the mother that are compressed 
betwixt the pubal or sacral bones and the child's cranium; or it causes 
inflammation to take place, to be succeeded by sloughing and its con- 
sequences. Or, the urethra being effectually compressed betwixt the 
cranium of the foetus and the symphysis pubis, a total suppression of 
urine takes place, followed by its very serious consequences; or, lastly, 
the soft parts, perhaps the vagina, or possibly the womb, being pinched 
as above stated, may give way during a pain, and the laceration, once 
begun, may extend so far as to allow the child to escape into the peri- 
toneal sac. 

Whenever, then, the head is found to be so situated that it will 
neither advance nor retreat, it may be said to be locked, and the case 
ought to command the greatest care from the medical attendant. 

It is manifest, that if the arresting points of the pelvis touch the 
head at its parietal protuberances, no possibility exists of applying 
the forceps in that direction ; there is not space enough to admit of 
the blades, and if they are to be applied to the head, it can only be on 
those parts that are free from great pressure, as the forehead, upon one 
side, and the occiput on the other; and this must be done notwith- 
standing any fear we entertain of contusions upon the face, of which 
there is some risk, but which very risk becomes less as it is the more 
constantly borne in mind. 

When the attempt to deliver in this case is about to be begun, the 
forceps should be well pressed together, so that, when the lever-like 
movement takes place, their blades may not be allowed to slip or slide 
upon the forehead, which would thereby be very liable to excoriation, 






FORCEPS. LOCKED HEAD. 505 

or even to be cut by their edges, formed, as is well known, for applica- 
tion to a convexity different from that of the face. The motion from 
handle to handle, assisted by a sufficiently powerful traction, will, 
ordinarily, succeed in disengaging the head, and getting it down into 
the excavation; upon which the blades ought to be removed, and, if 
the pains are revived and prove strong enough, they need not to be 
reapplied; but, in the lack of a proper force, they should be adjusted 
anew, and on the sides of the head, which is the part for which their 
curves were fashioned, and to which only they are really adapted. 

In making compression, let it be carefully remembered that that 
compression is not designed for the purpose of diminishing the dia- 
meters, but only to hold the object more securely or steadily; any 
amount of compressive action beyond this indispensable one, is mis- 
chievous, as tending to augment the difficulty, by forcing the parietal 
protuberances more decidedly against the arresting points. I suc- 
ceeded by this means in drawing a head through a pelvis so faulty in 
its antero-posterior diameter, that I could readily touch the sacrum, 
by introducing only the forefinger into the vagina. The patient was 
a very small woman of color, to whom I was called in consultation 
by a young medical friend; the child was dead, but not injured by 
the instrument. So great was the difficulty, that I at one period en- 
tertained very seriously the idea of performing the embryulcia. If I 
had known the child to be dead, I should have greatly preferred to 
do so. 

In these cases, the operator, who alone can estimate the degree of 
force he employs, is the sole judge as to whether that force is too 
great to be compatible with the safety of the woman: should he, upon 
a due consideration of it, deem it wholly unsafe to proceed, or im- 
practicable to succeed by any legitimate exertion of his strength, 
there remains the resource, sad as it is, of the perforator. Now that 
we have the advantage of the stethoscope, we can, with great cer- 
tainty, determine the question of the life or death of the foetus in utero ; 
and where we find, upon auscultation, that its life is extinct, we need 
have but little hesitation in applying the perforator, in order to reduce 
the size of the skull by extracting its contents. In doing this, how- 
ever unpleasant the operation, we remove much of the danger arising 
from a further continuance of the pressure on the soft parts of the 
mother. In case the stethoscope reveals the fact that the foetus is still 
living, we should feel constrained to wait so long as to overstep, per- 
haps, the boundaries of prudence. 

But it does not always happen that the head is locked in the direc- 



506 FORCEPS. PELVIC PRESENTATIONS. 

tion and situation above pointed out. The vertex may be jammed 
down behind the pubis, and the forehead in front of the promontory. 
Here the forceps can be legitimately adjusted; and they admit of the 
application of a greater force, and it will be probably found less dif- 
ficult to unlock and rotate the head, in consequence of the greater con- 
vexity of the points of arrest. Some degree of rotation ought to be 
given to the head by means of the forceps until they succeed in get- 
ting it down into the excavation, whereupon the vertex maybe rotated 
back again to the arch of the pubis, and so withdrawn. 

Impaction of the head cannot take place at the superior strait; the 
shape of that opening is such that its whole circumference cannot be 
filled by the head of a child; there would always be found a part of 
it in which not only the blade of a forceps, but a couple of fingers, 
would find passage; but after the head has sunk below the strait, the 
conical figure of the excavation perhaps admits of its whole circum- 
ference being occupied by the head, which fills it up completely, and 
so completely, that the forceps can find no space in which to pass. 
Let the attempt, however, be made, and in every unavoidable case, 
where it fails of success, the head can be opened, and the skull made 
to collapse. 

It only remains for me to relate the manner of applying the forceps 
in breech or footling cases, wherein the head refuses to come away 
after the shoulders are delivered. I have already said, that it is my 
invariable rule to have the forceps in readiness in every instance in 
which I discover that the head is to be the part last born. 

When the instrument is wanted for such a use, it is wanted sud- 
denly — immediately; and the medical attendant fails in his duty, who 
finds himself in want of forceps for this purpose, and is obliged to send 
for them ; for a child perishes while a messenger is going a hundred 
yards, or putting on his boots. 

There is no need of my going again at length over the causes that 
render the forceps necessary on these occasions. It is enough, that 
the expulsive powers are wanting, either from disproportion, from 
cessation of efforts both voluntary and involuntary, or from mal-posi- 
tion. If the head continues undelivered but a few minutes, the child 
is lost. 

Supposing that the shoulders are delivered, and the face in the hol- 
low of the sacrum; let a napkin be wrapped round the body of the 
child, including the arms, which should be placed against its sides, 
so as to keep them out of the way. Then, giving the body to an 
assistant, let it be held in a position nearly perpendicular, by the thighs 



FORCEPS. PELVIC PRESENTATIONS. 507 

or hips, so as to press the nucha against the arch of the pubis ; or its 
back may be carried over nearly in contact with the mother's abdo- 
men, to get it out of the way. The left hand blade, guided by two 
fingers of the right hand, is then to be passed in at the left side of 
the vagina, and applied to the head, covering it in the direction from 
chin to vertex. The right hand branch is next introduced, with simi- 
lar precautions, into the inferior and right side of the vagina, and so 
conducted on to the head as to embrace it from chin to vertex. As 
soon as the instrument locks, the tractions are to be commenced, and 
there will be, in general, little delay in the extraction, if the handles 
be raised as the head emerges; they requiring to be elevated, just as 
is needful in the delivery of occipito-anterior positions. If an ac- 
coucheur should attempt to perform this operation for a patient in any 
other than the dorsal decubitus, he would find himself greatly embar- 
rassed. 

But — if the child be unfortunately born with the toes towards the 
pubis, and rotation in the subsequent stages cannot be effected, so 
that the face is uppermost; if in this case, vain attempts to deliver 
by the hand have been tried; then, let the woman lie on her left side, 
with the thighs strongly flexed; let the child be turned bac^: as far as 
it can be done with safety to its neck, so as to bend the neck very 
much backwards. By giving to it this position, the forceps can be 
introduced in front of the child, the left hand branch being first passed 
up on the left side of the chin and carried as far as the vertex ; while 
the female branch is introduced upon the opposite side so far as to 
allow of its being locked w T ith the pivot. As soon as the head is pro- 
perly seized, let it be drawn downwards in such a direction as to cause 
the chin to emerge under the arch; to which end, let the handles be 
at first somewhat lowered. 

Where, however, it can be effected with proper celerity, it is better, 
for this application of the forceps, to bring the woman to the edge of 
the bed, and allowing the perineum to project beyond it, cause her 
feet to be supported in the usual manner. The child, wrapped in a 
napkin, can be well entrusted to a kneeling assistant, as it is held 
nearly in a vertical or standing position. The branches of the instru- 
ment have, by this means, free access to the left and right sides of 
the vagina, and they lock with the greatest ease in front of the throat. 
Except in such a position of the woman, I cannot conceive how it 
would be practicable to use the long forceps ; but Haighton's or Davis' 
forceps could be applied while on the side very easily. 

I say nothing here in regard to the operation of Symphyseotomy, 



508 SYMPHYSEOTOMY. 

commonly called the Sigaultian section, — an operation which was 
proposed and performed by M. Sigault, in the year 1777. 

The proposition to increase the dimensions of the planes of the 
pelvis, by cutting asunder the symphysis pubis, excited, soon after 
the promulgation of it, a great sensation throughout Europe, and many 
operations have been performed with various success. It is probable, 
however, that the increase of amplitude of the planes of the pelvis is 
not so considerable as the friends of the section at first hoped for, and 
the dangerous traction of the tissues behind the pubis, and the gaping 
of the sacro-iliac junctions, one or both, were causes of ill success that 
have allowed it at last to fall into complete desuetude. So far as I 
know, the operation has never been done in this country. I feel not 
the least inclination to recommend the performance of it, and I refer 
the reader, who may feel interested in inquiring into this method, to 
M. Baudelocque's work on midwifery, and to the curious work — 
Essais Historiques Litteraires et Critiques sur VArt des Accouche- 
mens, par M. Sue, le jeune, Paris 1779, 2 vols. 8vo. Dr. Churchill, 
in his " System of Midwifery," p. 376, gives the statistics of the opera- 
tion, as it has hitherto been done, and, in the most emphatic manner, 
discourages and condemns it. 

Before I close this chapter, I beg leave to reiterate the expression 
of an opinion which I have already uttered at page 486 — it is, that 
the obstetric forceps is the child's instrument; that the perforator, the 
crotchet and the embryotomy forceps, are the instruments for the mo- 
ther; and that the Csesarean operation, in its spirit and intention, should 
be devoted absolutely to the conservation of the mother alone. In 
saying so, I am not insensible of the great satisfaction to be enjoyed 
by that surgeon who, under the distressing duress which should alone 
compel him to subject a living woman to the Csesarean section, is 
rewarded with the happiness of rescuing both the child and its parent 
from the jaws of an otherwise inevitable grave. I hold that no man 
has a right to subject a living, breathing, human creature to so great 
a hazard as that attending the Csesarean section, from views relating 
to any other interests than those of his patient. 

I believe that the Csesarean operation ought not to be performed in 
any case, whether the child be living or dead, in which, under the 
dictates of a ripe and sound judgment and perfect knowledge of the 
principles of midwifery, a decision may be obtained that a delivery 
per vias naturales is less dangerous to the mother than that by vivi- 
section. 

Now, as to the question concerning the pelvis through which it is 



CiESAREAN SECTION. 509 

possible to deliver, I think it impossible to fix, as some writers think 
it desirable to do, a minimum aperture through which a woman may 
be safely delivered. Elizabeth Sherwood was delivered in a pelvis 
of one inch and three quarters, and I twice delivered Mrs. R. with 
a pelvis of two inches; but to say that a pelvis one inch and three- 
quarters is the lowest through which a woman can expel a child, is 
to speak contrary to the record. Indeed the dimensions of a pelvis, 
which by their reduction render a Caesarean section indispensable, 
are variable dimensions; these dimensions never can be fixed and 
prescribed by precept or law, for one woman may have strength and 
courage and endurance to enable her to bear a delivery in a pelvis of 
one inch and three quarters, as in Elizabeth Sherwood's case, whereas, 
in another woman the lapses of her strength may be so rapid, and 
the exigencies of her condition so urgent, that if she be not promptly 
relieved, she will be inevitably lost. Hence, it appears that my as- 
sertion is a correct one, that the dimensions demanding the Csesarean 
operation are variable dimensions. If we go down to diameters of 
one inch and a half, or to diameters of one inch, then the question of 
delivery per vias naturales is set aside. But we may find a case in 
which a woman, having a pelvis of two inches and a half, ought to 
be delivered by the section, because, in our judgment, we conclude 
that she cannot live long enough to escape by the slow process of a 
crotchet operation. I should not hesitate, therefore, to recommend 
the Caasarean operation in a pelvis between two and two and a half 
inches in one case, nor would I hesitate in another case to recommend 
an embryotomy operation in a pelvis somewhat below two inches in 
its diameters. 

I have been present in a consultation in which urgent demands 
and pressing arguments were in vain proffered to induce me to con- 
sent to a Csesarean operation; these arguments were based chiefly 
upon the claims to superior right of the child. In that case, as in all 
others, I was actuated in my opposition to the operation, by the firm 
opinion that the child has no fixed claims whatever, if they come to 
conflict with the right of its more important parent, and I regard my- 
self as not guilty of inhumanity in indulging or in expressing this 
sentiment, and I repeat a sentiment expressed upon page 469, in the 
quotation from Tertullian: " Atquin et in ipso adhuc utero, infans tru- 
cidatur necessarid crudelitati, quum in exitu obliquatus denegat partum, 
matricida qui moriturus" 

It appears to me to be a very important matter that the medical 
profession should have just views as to the performance of these grave 



510 CESAREAN SECTION. 

and direful operations. As I have great reason to think that many 
gentlemen, my brethren, have not given themselves time to reflect 
upon all the points of the indications, I am the more desirous to have 
an opportunity to state my own convictions in the matter, and I should 
be glad in the most emphatic manner to enter my protest upon the 
records of Obstetrics, against the Csesarean operation being performed 
with any other views than those relative to the conservation of the 
mother, with the salvo always, that to save the child is a great addi- 
tional good fortune. I believe that he who performs the Csesarean 
section upon views relative chiefly to the conservation of the fetus, 
flies in the face of the soundest doctrine ; and I cannot understand 
how the conscience of such an operator should ever be appeased 
under the pungent reflections that must follow a death not rendered 
inevitable by the exigencies of his patient. 

The number of cases of deformed pelvis met with in the United 
States, appears to be far less considerable than those met with in 
England or in the Continent of Europe. 



EMBRYOTOMY. 511 



CHAPTER XVI. 



EMBRYOTOMY. 



The implements employed in Embryotomy, or those operations in 
which the body of the foetus is cut by the surgeon, are various. They 
may, however, be all comprised under the denominations of: 1st, the 
perforator; 2d, the crotchet; and 3d, the embryotomy forceps. In 
cases, very rare ones, in which the decapitation of the child is re- 
quired, a knife of a peculiar form is to be had. I witnessed the de- 
capitation of a foetus thirty-five years ago, in 1813, and fortunately 
have seen no such operation since that one. 

Perhaps there is nothing to be met with in the very troublesome 
and anxious profession of an obstetrician, that is more painful to his 
feelings, than the management of a case of labor in which it is re- 
quired to mutilate the child, in order to extract it from the maternal 
organs. It is fortunate that this odious duty does not occur very fre- 
quently; and we are indebted to the inventor of the forceps, Cham- 
berlen, for an exemption from it in the present age in numerous in- 
stances, in which, without the important uses of that instrument, we 
should be compelled to resort to the perforator and the hook, which 
comprised nearly the sum of the instrumental resources of the ancients. 
We are also in modern times highly favored by the application of the 
stethoscope or direct auscultation, in acquiring greater certainty rela- 
tive to the life of the foetus, whose state of life or death can now be 
very accurately determined by that means; thus relieving the mind 
of a most painful solicitude by the certainty of its death, if that event 
should have happened, in cases in which we are compelled to apply 
destructive instruments for its delivery. 

When the foetal head is driven into the pelvis, and arrested there 
in consequence of disproportion of its diameters to those of the bony 
canal through which it is to be transmitted, if the arrest cannot be 
obviated by the hand, the lever or the forceps, there is danger that 
the mother may suffer so much constitutional irritation from the fruit- 



512 EMBRYULCIA. 

less efforts she makes, and the agonizing pain she endures, as to sink 
into exhaustion, and perish with the child still undelivered; and this, 
not only in the case of a cephalic presentation, but also in that of the 
feet, or that of the breech — in short, in all situations where the head 
cannot be got away through the pelvis except after it shall have been 
reduced in its magnitude. But even in those instances in which the 
woman is not threatened with exhaustion, she is liable, from the pres- 
sure of the head, to suffer inflammation or gangrene of the soft parts, 
which are contused by it, or she is exposed to the danger of lacerations 
of the womb itself, or of the vagina, wdiose consequences are greatly 
to be feared and deprecated. 

Exhaustion — manifested by cessation of the pains, smallness and 
great frequency of the pulse, a haggard and sunken countenance, 
anxiety, jactitation, coldness of the extremities, profuse viscous 
sweats, and delirium — may come on, in labors that are drawn out 
too long from smallness of the pelvis, and from rigidity of the soft 
parts; cases in which we may discern, very clearly, the necessity of 
immediate delivery, to rescue the woman from impending death. 
When such signs are present, and the child is known to be dead, if 
the ergot and the forceps are found, upon trial, to be unavailing, re- 
course must be had to the most speedy means of relief, to wit, the 
opening of the head and discharge of its contents, with a view to the 
collapse of the cranium. This object is effected by the introduction, 
into one of the fontanels or sutures, of the perforator, commonly called 
Holmes' perforator, the blades of which being afterwards opened, make 
a free incision, through which, if enlarged by a crucial cut, the cere- 
bral contents are either extracted at once, or allowed to escape slowly 
under the pressure of the pains. As soon as the opening is made, it 
is common to push the perforator deep into the cavity of the cranium, 
or to introduce a crotchet so as to break up the textures within, and 
then, seizing the head by means of the sharp hook, which is applied 
to any convenient situation on the outside or in the inside of the skull, 
to drag it through the vulva, and deliver it; after which, if the woman 
has not suffered too severely, she soon recovers of the effects of her 
preceding fatigue and severe pains. 

This is the simplest and easiest case of embryulcia, and is one that 
any humane practitioner would or might perform without hesitation, 
upon the proper grounds for the proceeding being fully set forth to 
him. 

Yet, notwithstanding the facility with which the operation of em- 
bryulcia may be performed, it is one so unnatural, and so shocking to 



EMBRYULCIA. 513 

the feelings of all concerned, that it ought not to be done without 
very satisfactory reasons for it ; and in general, not wi hout consulta- 
tion and agreement with a medical brother. In those instances in 
which it becomes necessary, during the life of the child, to resort to 
this mode of delivery, the most formal consultation ought to be regard- 
ed as indispensable ; and no consultation can be supposed properly to 
result in such a proceeding, except upon the most urgent and clearly 
understood reasons for it. There are gentlemen in the profession who 
boast that they never have performed this operation. It may be very 
true; but the reason is that they resolutely decline to do their duty, 
which they throw upon some not more unfeeling, but more merciful 
brother. 

There are cases of labor occurring in women with deformed pelvis 
that are plainly impracticable with an unmutilated child. For ex- 
ample, if a woman have the pelvis occupied with an exostosis, or if 
the diameters of that canal are changed and spoiled by rachitis or by 
malacosteon, the child contained within her womb cannot escape 
whole per vias naturales. If the promontory of the sacrum comes 
within two inches and a half of the symphysis pubis, the child cannot 
pass the strait alive, because its own smallest diameter is more than 
three and a half inches; and indeed, if the pelvis have three inches 
of antero-posterior diameter, it cannot be born alive, unless it be un- 
commonly small, and moreover possessed of a very incomplete ossifi- 
cation of the cranial bones, and great laxity of the suture lines that 
unite them: such a head might, by long pressure under a very power- 
ful worab, be at length forced down through the strait, after it should 
have been moulded into the proper form by the force applied to it. 
Yet, when we come to consider that the bi-parietal diameter is 3.88 
inches, we shall entertain little hope of getting the head down, in a 
pelvis of three inches. It is very true that Solayres and Duges and 
others have been fortunate enough to meet with cases in which the 
head at term has been born in a pelvis of two and a half inches 
from front to rear; but it is not to be expected that success can attend 
labor in a female whose pelvic deformity even approaches to tw T o 
inches and a half in its smallest line of diameter. The exceptions 
but prove the general rule. (See Monthly Journ. Sci., July, 1847, for 
Dr. Simpson's case.) 

Such a pelvis is not fit for the forceps, since it is too small for them 
to be withdrawn when locked. The question must always be, there- 
fore, between the perforator and crotchet on the one hand, and the 
Caesarean section on the other. But this is only to be considered as 
33 



514 EMBRYULCIA. 

relative to the living child. Of the dead child, no question can arise 
as to the mode of its delivery, except that of the perforator, and 
whether sooner or later. The dead child must always be 
withdrawn per vias naturales, if there be space enough 
to extract it through with equal safety. But even where 
the child is known to be dead, we may be compelled to perform the 
Cesarean operation, if we would deliver the woman at all; since 
deformity may reach to the degree of shutting up the passage, even 
against the perforator. There is, in the museum of the University of 
Pennsylvania, a pelvis so distorted, that the hand could not possibly 
have directed an instrument to the head, in a manner to enable the 
surgeon to open and extract it. The woman from whose remains the 
pelvis was taken, died in the Almshouse, resolutely rejecting the 
Csesarean operation, and preferring to it the death which she knew 
to be inevitable. 

The practitioner who may be in charge of a case of labor where 
embryulcia is indicated, must be guided by his judgment and the 
counsel of his medical brother as to the signs which compel him to 
undertake the delivery. I have already enumerated them — and they 
are easy to be understood. There is, in general, far more danger of 
the operation being deferred too long, than of its being performed too 
soon, since, if it be not performed in time to save the life of the 
mother, it would be as well not to do it at all. I know that, in utter- 
ing this sentiment, I am liable to the imputation of wantonly encou- 
raging the use of this dreadful operation, but I wish to disclaim such 
an intention. I hope that no man living is reasonably more reluctant 
than I am to use any obstetric instrument whatever; and I fear that 
the resort to its employment is often had very unnecessarily and 
rashly. But I think that, when the case under consideration arises, 
we ought to act so promptly and so understandingly, that we may, on 
the one hand, derive a perfect success from it, and on the other, stand 
acquitted, in our own judgment and in that of others, from the charge 
of any rashness or precipitation. I shall strive, therefore, while I 
reiterate the opinion, to clear myself by repeating, that all such cases 
require a medical consultation. To mutilate the child, and then lose 
the mother, is a real misfortune, both for the practitioner himself and 
for the profession, which, from such results, is in danger of falling into 
disrepute. 

It is to be understood, then, that where all other instrumental means 
fail — where, after due reflection upon the circumstances that hinder 
the delivery, a conclusion is formed that the mother and child must 
both perish, unless the latter be withdrawn by the assistance of in- 



EMBRYULCIA. 515 

struments that mutilate it — where the Cesarean operation is inad- 
missible, or rejected by the patient, we have the remaining and very- 
sure resource of the operation of embryulcia, or embryotomy; and 
we can venture to encourage and cheer the unhappy and suffering 
female with the prospect of speedy relief by its means. 

I have had occasion to feel, in common with other practitioners, 
how dangerous an instrument is the sharp crotchet. The force to be 
employed on it, in extraction, is so great that, should the point slip 
or tear out from the bone, it is always jerked downwards several inches, 
and is very apt to catch in some of the soft parts of the mother, which 
are ploughed up and lacerated by it. How easy it would be to lace- 
rate the vagina, or even the lower part of the womb, by the slipping 
of the point; and nevertheless, he who uses the crotchet, and is per- 
fectly aware of the risk, is under the necessity of running that risk 
whenever he takes the instrument in his hand to deliver with it. 
There is no part of the cranium to which it can be applied without 
some hazard of its losing its hold. This is most apt to occur from 
the faulty manner in which the crotchet is generally made, namely 
with iron and not with steel. With a point of soft iron there is no 
real security; because the point soon becomes dull, and does not 
maintain its hold of the bone. The point ought to consist of well 
tempered steel, and should be made as sharp as possible — but very 
much beveled. 

There is a vast variety of instruments prepared for the delivery of 
the head in cases of deformed pelvis. Dr. Davis of London has in- 
vented a great number of them, some of which I have had occasion 
to use, but with less satisfaction than I expected to have, from the 
strong recommendation bestowed upon them. I am now well con- 
vinced, that a great apparatus of this sort is not at all necessary, as I 
think will be conclusively shown in the sequel of this article, in which 
I shall describe an instrument capable, with the occasional aid of one 
sharp crotchet and a perforator, of effecting the delivery of the head 
in the most restricted pelvis from which delivery is at all possible. 

As this volume is not designed to be drawn out to a great length, 
I am constrained to make many of the remarks that I could otherwise 
find occasion to offer, more brief than is compatible with a copious 
detail of the subjects. But, notwithstanding this necessity, I am in- 
duced to give at length, the history of a case of labor in a deformed 
pelvis that was under my notice in the year 1831. It was drawn up 
by my friend Dr. George Fox, and published in the North American 
Medical and Surgical Journal, vol. xii. p. 484. It may, perhaps, 
serve sufficiently well to set forth the difficulties and embarrassments 



516 EMBRYOTOMY. MRS. R.'s CASE. 

with which such cases are surrounded, and the success of it, probably 
the most difficult obstetric operation ever successfully performed in 
this country, may encourage those who shall hereafter have the mis- 
fortune to contend with similar cases, to hope for success in the midst 
of the greatest obstacles. I consider it more instructive than any 
merely didactic remarks that I could compress into these pages. 
"On Tuesday, June 14th, 1831, I was called about seven, A. M. 

to see Mrs. R in labor with her first child: this is stated to 

have commenced about one A. M. The pains, as are usual in the 
commencement of labor, were feeble, short, and at about ten minutes' 
interval. Upon examination per vaginam, the projection of the sa- 
crum was immediately felt: not, however, suspecting the deformity 
which was subsequently found to exist, this was not at the time par- 
ticularly attended to; the os uteri was sufficiently dilated to admit the 
finger and feel the protruding membrane. I was struck with the form 
of ihe sacrum : the rectum being very much distended with feces, I 
thought it might, in part, be occasioned by this. Directed ol. ricini 
one ounce, which was taken immediately. At noon found, upon ex- 
amination per vaginam, that the membranes had ruptured, the head 
presenting: she was not aware at what time the waters had escaped. 
In the evening, the rectum being unloaded by the operation of the 
oil, I made a more minute examination, and was sensible of great 
deformity of the pelvis, though not to the extent we afterwards ascer- 
tained, the pains not being at all active. As it was late, I determined 
not to ask the assistance of my medical brethren till the following 
morning; therefore directed an anodyne (which I subsequently ascer- 
tained was not taken, from her dislike to laudanum and fear of its 
retarding her labor) and left her for the night. Was called up about 
one o'clock the next morning, her pains being more frequent and 
stronger; found the os uteri rather more dilated, and the external 
parts very rigid, preventing an accurate examination of the pelvis. I 
remained with her some hours; subsequently called upon Dr. James, 
late Professor of Midwifery, &c, in the University of Pennsylvania, 
who met me in consultation at half past eight A. M. In consequence 
of the rigidity of the soft parts, we found it impossible to make any 
satisfactory examination ; we therefore concluded it best she should 
be bled and take an anodyne — that we would meet in the afternoon: 
she was accordingly placed erect in bed and bled to incipient syncope, 
which was after losing about fifteen ounces; twenty drops of laudanum 
were soon after given. In the afternoon Dr. James again saw her: 
from as accurate an examination as we were capable of making (for 



517 

the external parts still continued rigid, though somewhat relaxed since 
the bleeding), we came to the conclusion that there were not at most 
three inches in the antero-posterior diameter; that laterally there was 
rather more room, on the left more than on the right; the posterior lip 
of the os uteri was swoln and succulent, forming a cushion in front 
and a little below the projection of the sacrum; the head was present- 
ing to the left side — its exact position could not be determined. On 
account of the unusual interest of the case, Drs. Meigs and Lukens 
were invited to attend ; Dr. James, not feeling quite well, did not meet 
us that night. The result of the examination of these gentlemen w r as, 
that there was not more, if as much, room at the superior strait as we 
supposed; they coincided with us in the opinion that it w r as impossi- 
ble the child should be born alive per vias naturales: our next object, 
therefore, was to ascertain whether or not the child was living; this 
was rendered certain by the application of the stethoscope ; the pulsa- 
tions of the child's heart were distinctly perceived, whilst the pla- 
cental souffle was also very evident; the pains continued as they had 
been most of the day, recurring every four or five minutes. We re- 
mained with her some hours, when we ordered her an opiate, and 
agreed to meet at four A. M. The result of this meeting was, that, 
as the proper means of proceeding were of such immense importance, 
further advice should be had, and that we should meet at half-past 
eight o'clock A. M. Dr. Physick was called on, but was confined to 
the house by sickness ; Dr. Dewees was also called for, but was absent 
from the city. At half-past eight A. M., Dr. James met us, Dr. Hew- 
son being added to the consultation: it was agreed, as before stated, 
that it w r as impossible the female should be delivered of a living child 
per vias naturales ; the question then was, whether the child should 
be sacrificed to save the mother's life, or an attempt made to save 
both mother and child. It was concluded, as the strength of our 
patient was good, her pulse only eighty-four and strong, as there were 
no symptoms of constitutional irritation, no injury would result from 
a few hours' delay; we therefore separated to meet at twelve M. 

"The consultation was held at the appointed hour; by this time, 
after repeated and the most accurate examinations that the case ad- 
mitted of, we were unanimous in the opinion that there w r ere not more 
than two inches in, the antero-posterior diameter, most probably only 
one inch and three-quarters. The different methods of proceeding 
which have been proposed in similar cases were duly and maturely 
considered, namely, the division of the symphysis pubis, the Csesarean 
operation, and cephalotomy: the first was considered inapplicable to 



518 EMBRYOTOMY. MRS. 

the present case; the Cesarean operation was thought to be attended 
■with so much risk to the mother, as almost to be necessarily fatal, 
some of the most distinguished surgeons being decidedly opposed to 
its performance. Dr. Physick, who was called upon in the course of 
the morning by Dr. Meigs and myself to ask his opinion on the pro- 
priety of this operation, was decided and positive in his opposition to 
it. Under the weight of such authority, the idea of the Csesarean 
operation was abandoned. It was therefore concluded, after the most 
mature deliberation, and upon viewing the case in all its bearings, 
that the life of an imperfect being (for it was again ascertained that 
the child was living and apparently vigorous), should be sacrificed to 
save the life of a wife and daughter, and that the operation should be 
immediately commenced, by opening the child's head, breaking up 
the brain, and allowing some hours to elapse before attempting ex- 
traction. At my request, with the approbation of our colleagues, Dr. 
Meigs consented to perform it. Drs. James and Hewson, having pro- 
fessional engagements, were at this time obliged to leave us, to meet 
again at six o'clock P. M. Preparatory to the operation, the rectum 
was unloaded by an enema, the urine drawn ofF by a catheter, and an 
anodyne administered; her pulse was one hundred and four. The 
consent of the patient, her husband and friends, having been obtained, 
she was placed at the foot of the bed (which had previously been ad- 
justed), the hips being on the edge, so that the perineum was perfectly 
free, an assistant supporting each leg. Dr. Meigs then took his seat 
directly opposite ; made another examination preparatory to beginning 
the operation. After having some time carefully examined, he called 
me, and subsequently Dr. Lukens also, to make another examination, 
the result of which was, that the operation of cephalotomy, if not 
altogether incompetent to the delivery, would be attended with as 
much risk to the life of the mother as the Csesarean operation : it then 
appeared to us impossible that the cranium should be removed and 
the base brought through the superior strait, without the most violent 
exertions and great danger of lacerating the cervix uteri, vagina, &c. ; 
that, taking this view of the case, it was better to call our colleagues 
again together, at as early an hour as possible, to reconsider the pro- 
priety of performing the Csesarean operation: the child was again 
ascertained to be alive. 

" Accordingly, at five P. M. we again met. Dr. J. Rhea Barton at 
this time saw our patient. Our first object was to ascertain respecting 
the life of the child, and upon applying the ear and the stethoscope, 
no pulsation was perceptible in any part of the uterine region; it was 



EMBRYOTOMY. MRS. R.'s CASE. 519 

then unanimously agreed (the female not having felt the child for two 
or three hours) that it was dead: there was now no further hesitation 
as to the propriety of cephalotomy, which was immediately performed 
by Dr. Meigs, who employed the utmost assiduity and care in the 
management of the operation, on whose skill and unwearied attention 
the success of it is mainly dependent; to him I am also indebted for 
the following account of the difficulties, &c, which were experienced 
in the accomplishment of the delivery of the child. 

" * The woman being conveniently placed on her back, with the 
perineum projecting beyond the edge of the bed, and the legs and 
feet properly supported by an assistant on each side, I took my seat 
for the purpose of proceeding with the first part of the operation, the 
perforation of the cranium. 

" ' A suture crossed the pelvis from front to rear, but its edges were 
overlapped, and could afford no facilities for the operation. This 
suture was the right leg of the lambdoidal, as was afterwards ascer- 
tained. 

" l With Botschan's improved craniotomy scissors, I endeavored to 
penetrate the solid bone in the centre of the strait, but, owing to the 
narrowness of the passage, and the constant interference of the os 
uteri, the lips of which were nearly in contact antero-posteriorly, I 
dared not to give to the instrument that rotatory or drill-like motion 
which was necessary, for without such a movement it was impossible 
to make any progress, as the head rose upwards and rolled freely in 
the superior basin whenever any considerable pressure was applied 
by the perforator, though the womb seemed to be pretty firmly con- 
tracted at the same time. 

" ' Finding this mode of proceeding unsafe for the woman, I begged 
permission to leave her a few minutes in order to procure an instru- 
ment better adapted to the purpose in hand. Accordingly, Mr. Rorer 
furnished me with a large trocar, and having guided it with two fingers 
to the proper situation and kept it securely by retaining the fingers in 
contact with the head, I was able gradually to drill a hole through 
the bone, the head being pressed from above against the strait by Dr. 
Lukens. Two other perforations were made near to the first one, in 
the same cautious manner; after which, I again introduced Botschan's 
scissors, and having opened them, found that I had made an incision 
of about an inch and a half in length. Through this a slender blunt 
hook was introduced into the. cavity of the cranium, and the brain 
very freely broken up. 

" c The poor woman, who was already very much exhausted by 



520 EMBRYOTOMY. 

many hours of labor, now took an anodyne and was left to her repose, 
in order that the medullary matter might be gradually pressed out, 
and the cranium allowed to collapse so as to come more in reach of 
the instruments. 

" ' At ten o'clock P. M., I again met Drs. Fox and Lukens, and the 
patient being disposed as before upon her back, I introduced a crotchet 
into the cavity of the cranium, and spent some time in extracting the 
medullary substance, not much of which seemed to have been ex- 
pressed during our absence; the head still continued on the superior 
strait, except a portion of the hind head, which was pressed down into 
the excavation to the left of the promontory, where there appeared to 
be the largest space. 

" * Having removed a considerable quantity of the cerebral sub- 
stance, I fixed the tooth of the crotchet into the cranium, and guarding 
it on the outside with a finger, exerted a very great amount of force, 
which had not the least effect in drawing it lower down. 

" 'It soon became evident to me, from several trials of this kind, 
that no exertion of mere strength could be of any avail to drag away 
the head, and that if it was to be delivered at all, it must be piece- 
meal : but as the child had been dead only a few hours, and its skull 
bones were still firmly united to their inner and outer membranes, it 
will be readily conceived that the removal of the bones was a most 
difficult matter, not only on account of the firmness of their connec- 
tions, but also on account of the narrowness of the passages, the great 
hardness of the skull, and the great danger of wounding the parts by 
the slipping of the crotchet, which, under the circumstances, could be 
best applied on the interior of the skull, and from the swoln and suc- 
culent state of the lips of the os uteri, whose inner surfaces were in 
contact, and presented to the touch the idea of a long fissure instead 
of preserving a round or oval form : last and not least, the perineum 
was so strong and unyielding, that the greatest inconvenience arose 
from its pressing the fingers against the arch of the pubis with such 
force and by long continuance so painfully, that no one could endure 
for any great length of time to keep up the necessary extension. 

" 'Being possessed of one of Dr. Davis's osteotomists, I expected 
to derive great advantages from its employment in the case, and ac- 
cordingly introduced it with the view of cutting away portions of the 
bone, but the constricted state of the parts rendered it impossible to 
make use of it consistently with a humane regard to the safety of the 
patient. 

" < Having ascertained, then, by fair experiment, that mere force 



EMBRYOTOMY. MRS. R. S CASE. 521 

could do nothing in the delivery, I resolved to pursue the intention of 
breaking up the head by means of the crotchet; and it was with great 
fatigue to the woman that I picked out altogether about as much as 
would equal the size of one of the parietal bones, the portions consist- 
ing of fragments of the right parietal and part of the frontal bone. 

" * Finding, towards morning, that the progress of the operation 
was exceedingly slow, I went out and procured a pair of straight tooth 
forceps, with which I could take a firm hold of the bone and twist off 
portions, which, after they were broken away, often took a good while 
to separate from their adhering membranes. 

" ' At four o'clock the woman was so much fatigued, that we agreed 
to give her an anodyne draught, and leave her to recover strength by 
means of a few hours' rest. 

" * The attempts at extraction had now continued from ten o'clock 
P.M. until four A.M., and I think the whole of the bone removed 
would not much exceed in quantity one parietal bone at full term ; it 
seemed impossible to proceed with greater rapidity, and I often ad- 
mitted a doubt whether I should be able to deliver her before death 
should come to her relief. 

" 'Throughout the day, on Friday, the attempts at extraction were 
repeated, in presence of the gentlemen last named, and also of Drs. 
James and Hewson, who became fully satisfied, that no greater pro- 
gress could at present be made, considering the circumstances of the 
woman. 

" ' Early in the afternoon, symptoms of fever became very manifest ; 
the pulse rising to one hundred and twelve strokes in the minute, with 
considerable firmness and volume ; this state of the circulation being 
coincident with a distressing eructation partaking somewhat of the 
character of singultus, and a great distension of the abdomen, as well 
as of the womb itself, from gases extricated within them. She com- 
plained also of great soreness of the belly, on which account she had 
it bathed frequently w T ith cold vinegar and water, leaving the surface 
exposed to the air. 

" 'In order to counteract this new state of things, she was bled six 
ounces, and took a portion of castor oil. 

" * Dr. James, who had witnessed in the morning the difficulty with 
which the extraction of portions of the cranium was effected, was 
good enough to supply me with a complete set of Dr. Davis' cranio- 
tomy forceps, and returned to the house in the afternoon to our assist- 
ance. These instruments were applied, but they were incapable of 
effecting so much as even the straight tooth forceps. The teeth of the 



522 EMBRYOTOMY. — MRS. R.'s CASE. 

instrument could not be made to penetrate the skull, although most 
accurately adjusted; and notwithstanding the handles were brought 
so nearly together, that the style on the one handle went quite to the 
bottom of the socket in the other, every attempt to extract with them 
resulted in the slipping of the bone out of the gripe of the instrument; 
a proof at once of the hardness of the bone, and of the impossibility 
of bringing it down in its then condition. 

■ " l Putrefaction now rapidly advanced, as indicated by the odor of 
the discharges, and my only hope for the escape of the patient rested 
on the opinion, that she might be supported a few hours, Until the 
softening of the tissues should enable me to draw down larger portions 
of bone by admitting of the pericranium and dura mater being peeled 
off with a finger nail, while the bone should be secured, and drawn 
down with the forceps or crotchet. 

" ' But such was the unpromising state of affairs, that the poor 
creature resolutely refused to make any further effort to escape, saying 
she knew that she must die, and would rather die than exert herself 
any further, and begged in the most piteous tones that all further at- 
tempts to deliver her should be abandoned, yet expressing her thanks 
for the efforts that had been already made. 

" ' She was at times slightly delirious. After explaining to her the 
increased facility which began to exist from the rapid decomposition 
of the foetus now going on, and endeavoring to reassure her with a 
promise to deliver her in the course of the night, she was again left 
to rest three or four hours under an anodyne draught. During the 
whole period that has now been spoken of, the anterior lip of the os 
uteri was behind the triangular ligament of the pubis, and the posterior 
low down beneath the promontory, and strangulated, as it were, or 
buttoned by the part of the head that lay on the strait and partly within 
it; yet so swelled, that their inner surfaces continued nearly in con- 
tact, except when parted by the introduction of the fingers. 

" ' The perineum seemed to have acquired no disposition to relax, 
notwithstanding all the handling to which the parts had been subject; 
and, excepting that the bones were more easily detached now than 
before, no greater comfort or facility was enjoyed by the operator than 
at the commencement. 

" ' At ten P. M. I again met Drs. Fox and Lukens, and the patient, 
after much entreaty and argument, resigned herself unwillingly to the 
further prosecution of our attempts to deliver. The remains of the 
head were still high up, but some of the broken edges came lower 
down. I got hold of a piece that descended behind the pubis, and 



EMBRYOTOMY. MRS. R.'s CASE. 523 

with the tooth forceps pulled it downwards, detaching the membranes 
as it advanced, and found that it consisted of all the remainder of the 
right parietal bone. I next got away nearly the whole left parietal, 
and afterwards with the crotchet removed first the right, and then the 
left orbitar portion of the os frontis, which was all that remained of 
that bone. I then got away with the crotchet and forceps the right 
superior maxillary, and afterwards the left superior maxillary bone. 
I subsequently twisted off the greater part of the broad portion of the 
os occipitis, and the squamous parts of the temporal bones; so that I 
had nothing left now but the base of the skull and the lower jaw, 
which latter I left as a point on which to exert the tractions that were 
soon to be required. 

" ' If the estimate made by all the gentlemen, that the strait was 
not more than two inches in its antero-posterior diameter, should prove 
correct, I was fearful of meeting some difficulty in bringing the base 
of the skull, which was- two and a half inches, through it; but when 
I had reduced the head so as to leave nothing more than the base of 
the skull and the lower jaw, I fixed a blunt hook into the latter, and, 
with a finger to antagonize it, drew the mass down towards the point 
of the coccyx, and had the satisfaction to find that it was got quite 
through the strait. My hand being now introduced into the vagina, 
I got a firm hold of the neck, and with the exertion of the greatest 
strength, gradually brought the button-like remainder of the head out 
at the vulva, while the point of the thorax, of course, was entering 
the narrow pass. The head was delivered at a quarter after one 
o'clock, and having succeeded in effecting the most difficult and dan- 
gerous part of the operation, we gave her some ergot; then fastening 
a twisted towel round the neck of the foetus, I renewed the extractive 
efforts, which in twenty minutes enabled me to deliver the shoulders, 
and in twenty minutes more, the hips — the child being completely 
withdrawn at five minutes before two o'clock, which was forty minutes 
after the head was delivered. 

" 1 1 found that, under the stimulation of the ergot, she was enabled 
to bear down very strongly, considering her exhausted state, and at 
all events the chief object of its exhibition was secured, namely, a 
firm contraction of the womb, and an effectual separation of the pla- 
centa, which came into the os uteri soon after the delivery. 

" ' Large quantities of gas of the most putrid odor followed the 
extraction of the child, showing the enlargement of the womb, before 
spoken of, to have been owing to its extrication by the putrefactive 
processes going on in the uterine cavity. 



524 

" ' The cord was shrunk and black, and the placenta, which was 
likewise black, and so filled with air as to crepitate under the fingers, 
was so horribly noisome that it was scarce possible to endure it during 
the requisite handling of it. No blood followed the placenta. 

" * The body was soft and putrid, being completely emphysematous 
and crepitating like the placenta. The cuticle was peeled by the 
pressure and friction. 

" ' The child was rather above the medium size. 

" * After washing the poor creature with a sponge dipped in claret 
and water, and making her as dry and comfortable as possible, she 
got an anodyne and was left to rest, being unable to speak above a 
whisper, and with a pulse feeble, but beating only one hundred and 
two strokes per minute. 

" * The whole difficulty in delivering a child through so contracted 
a pelvis, can scarcely be conceived of by one who has not been en- 
gaged in such an operation. The constant and perplexing apprehension 
of injuring the mother, either with the instruments employed, or with 
the sharp and ragged edges of the bones which must be withdrawn, 
and sometimes violently broken off with the sharp tooth of the crotchet, 
involves the operator in the most painful and unremitted attention 
and watchfulness, which alone, when long continued under compul- 
sion, is a real torture. The confusion also in the parts, arising from 
the ragged remains of the scalp and the inner and outer membranes 
of the cranium blending themselves, as it were, with the lips of the 
os uteri, and covering and concealing the bones, is a source of great 
embarrassment, where those fibrous tissues retain so much firmness 
and compactness. 

" ' Doubtless, could we have known that the woman would have 
been able to bear the fatigues of labor so long, we should have de- 
ferred the efforts at extraction for twenty-four hours after the perfora- 
tion of the head; but such was not the opinion to be gathered from 
the actual phenomena. 

" ' It has been seen that no great loss of time took place, after the 
softening of the tissues rendered it possible to break them up with 
some facility, whereas the process previously was exceedingly slow 
and tedious. The perforation was deferred as long as possible, which 
saved us from the dreadful and cruel operation of cephalotomy in a 
living foetus. The child died from long-continued pressure.' 

"June 18th (Saturday), nine A. M. Our patient says she feels 
quite comfortable; had some sleep after we left; pulse one hundred 



525 

and twelve, rather more feeble ; skin moist, tongue slightly furred ; 
clean linen, &c., was put on her, and she was moved up in bed. The 
bladder was emptied by the catheter; fomentations with flaxseed 
mucilage directed to be applied to the vulva; the most perfect rest 
and quiet strictly enjoined; as diet, arrowroot and oatmeal gruel, 
tea and toast. 

"Evening. Remains much the same; bladder again emptied; 
mucilages continued; an anodyne to be given at ten P. M., if at all 
restless. 

" 19th, nine A. M. Passed a comfortable night, pulse ninety-four, 
skin pleasant, tongue slightly furred, lochia almost natural; free from 
pain; slight soreness over pubis to left side; directed warm brandy 
to be applied over soreness, a Seidlitz powder to be given, and re- 
peated, if necessary; continue other means. 

"Evening. Medicine not having operated, an enema of warm 
flaxseed mucilage was directed, and an anodyne at bed time. 

"20th. Rather restless in the early part of the night; enema ope- 
rated freely; feels very comfortable; no pain; pulse seventy-six; skin 
pleasant; tongue continues slightly furred; countenance good; spirits 
cheerful; continue as before. 

" 23d. Our patient continues to do well, usually rests well at night ; 
free from pain, although the soreness in uterine region continues; 
secretion of milk copious; feels so comfortable that she has taken an 
infant to nurse ; pulse rather more frequent than natural ; tongue clean 
and moist, bowels costive ; passes urine without difficulty — the cathe- 
ter was used three times daily till last evening, when it was found to 
be unnecessary; lochia serous; directed ol. ricini one ounce. Muci- 
lages to vulva to be continued, mucilaginous injections per vaginam ; 
continue diet, and perfect rest in horizontal position. 

" From this time our patient continued rapidly to improve ; in 
three weeks from the time of her delivery, was so well as to be per- 
mitted to go down stairs, and in a short time resumed her ordinary 
avocations. 

" The subject of the preceding case is a native of Ireland, aged 
about twenty-two years, of small stature, not exceeding four feet and 
a half; is stated to have been a healthy child till her third year, when 
she received an injury by a fall, after which she was unable to stand 
or walk for two or three years; at the expiration of this time she re- 
gained her strength, and was subsequently considered an active child. 
Upon examination, we found the femur and tibia of each extremity 
very much curved, forming a considerable arch forward ; at the lower 



526 MEIGS' EMBRYOTOMY FORCEPS. 

part of the spine, there was a cavity sufficiently large to admit the 
hand corresponding with the promontory of the sacrum internally; 
the bones of each arm partook of the general disease. It was evident 
she had in early life labored under rickets." 

In cases where the diameters of the pelvis have been so much 
diminished by rachitis or mollities ossium as to render the descent 
of the fcetal head impracticable, it has been the universal custom 
either to perform gastrotomy, or to lessen the size of the cranium by 
evacuating its contents, and then to make extraction by means of the 
sharp crotchet. 

The method last spoken of is a good one, perhaps, and succeeds 
well enough where the diminution of the pelvic passages is not too 
considerable: nevertheless, we find, upon reference to the records, 
that a great many women have been the victims of such untoward 
labors, owing, measurably, to the violence done to the soft parts during 
the forcible extraction of the head, which was, perhaps, insufficiently 
reduced in size to admit of its transmission with safety to the mother 
— and probably in no less degree to the wounds that have been in- 
flicted by the slipping of the crotchet — a very common, and often 
unavoidable, accident in its employment. The crotchet, to say the 
least of it, is a detestable instrument. 

The firm bony structure, composing the base of the fcetal skull, is 
nearly two inches and a half in its transverse or smallest diameter; 
mere excerebration, therefore, cannot be regarded as furnishing a 
good security against fatal contusions from the forcible extraction of 
such a body from a pelvis whose smallest diameter is not exceeding 
two inches in length. Such a body as the base of the skull must, 
in order to pass through such a pelvis, present itself in an inclined 
attitude, or with a dip, but this dip or inclination can be only imper- 
fectly communicated to it whilst all the bones of the cranium retain 
their connexion with each other. To enable such a base to pass 
downwards safely, the skull ought to be taken to pieces, and those 
pieces removed in succession. In some instances, this successive 
ablation of the cranial bones has been effected by the crotchet, the 
point of which was used to pick out the bones, sometimes in portions 
not larger than the finger nails ; as, for example, in Elizabeth Sher- 
wood's labor, impressively narrated by Dr. Osborne. Those who 
have perused that account, will remember the extreme perplexity of 
that practitioner, and the infinite pains he took in his anxiety to avoid 
injuring her with the crotchet. He could not get the base of the 
cranium down until he had removed all the rest of the head. 



527 

Having had occasion to observe the difficulties and perplexities 
arising from labor in deformed pelvis, as they occurred in Mrs. M. 
R., the case above related, whom I have now delivered in two ac- 
couchements, I venture to lay before my professional brethren the 
impressions I derived from observing and conducting those two 
labors. 

There is reason to believe that no other female has ever been safely 
delivered in this country, under the disadvantages of a pelvis measur- 
ing only two inches from sacrum to pubis, which, by the judgment of 
persons of the highest claims to confidence, is the extent of Mrs. 
R.'s case. I speak this, however, under liability to correction. All 
the gentlemen then consulted, agreed that the diameter was as above 
mentioned. 

Her second accouchement took place in the month of June, 1833, 
the child having reached the full term of utero-gestation, an event 
which I greatly deprecated, having vainly urged, with the advice of 
Dr. Dewees, the operation for inducing premature delivery. 

The experience I had acquired in delivering her in the first labor, 
convinced me that the crotchet was not to be relied upon in her case ; 
not only because of the danger from contusion in extracting the 
skull, and from wounds made by the point of the crotchet, but also 
from the loss of time requisite for picking out the head bit by bit. 
The patient had almost fallen a victim to exhaustion in the first 
instance. 

In reflecting upon the facts that had occurred in 1831, 1 found that 
the problem about to be solved in the second labor, was not, a head 
being retained above a pelvis too small to transmit it, to extract said 
head — but the question was, to extract said head with the smallest loss 
of time, and least possible risk to the mother. I had already ascer- 
tained that the Caesarean operation would not be submitted to. 

I supposed that the head might be four inches in its bi-parietal 
diameter, and I knew that the pelvis was only two inches. Under 
such circumstances, the vertex will not present, but the crown of the 
head will be the presenting part : but since the cranium cannot recede 
farther than is necessary to bring it in close contact with the posterior 
part of the mother's abdomen, there will be two inches of the head 
lying upon the plane of the superior strait, and two other inches pro- 
jecting in front of the symphysis pubis: or, in other words, the crown 
of the head will repose upon the top of the symphysis pubis — part 
of the head being behind, and part in front of that bone. 

There is a very important principle in the management of such a 



528 



MEIGS EMBRYOTOMY FORCEPS. 



case, which is, that all that part of the cranium which lies in contact 
with the mother's back, is perpendicular to the opening of the strait, 



Fig. 119. 



Fig. 118. 



Fig. 120. 




and may, when the skull has been opened, be seized with a straight 
forceps or pliers, like that represented in the engraving Fig. 118, 
whereas, all that part of the skull that lies horizontally over the open- 
ing, can be taken hold of with a curved forceps or pliers, as is seen 
in Figure 119. Long before the occurrence of Mrs. R.'s second 
labor, I caused the proper instruments, Figs. 118, 119, and 120, to be 
prepared by Mr. John Rorer, the eminent surgeon's instrument maker. 
By means of this apparatus, I encountered but little difficulty in de- 
livering this patient, whose first accouchement had cost me so much 
toil and anxiety. The invention is my own. I published it soon 
after the event spoken of, in a Baltimore Journal, and it is now known 
and used in this country as my embryotomy instruments. Mulder, 
nor any other author has described or proposed it. I look upon it as a 



529 

most important contribution to the operation in midwifery. In a great 
majority of the cases it supersedes the crotchet, and mitigates the 
danger of the embryotomy operation in a remarkable manner. 

I have found, upon applying the test of practice, that when the thin 
portions of the cranial structure are taken hold of, either with the 
straight or curved forceps, they can be broken up with great ease, and 
removed with sufficient celerity; so much, indeed, that a head may be 
reduced to a very small remainder in a short time. I believe that if 
early arrangements are made for delivering the patient by this method, 
no danger will exist, of exhaustion or excessive constitutional irritation 
being produced, before the extraction of the foetus can be completed. 

From the foregoing remarks, it seems to be very clear, that the 
practitioner, in undertaking to deliver a patient with excessive distor- 
tion of the pelvis, ought to proceed to his operation with a full under- 
standing that, after perforation, he is to remove all the posterior parts 
of the presentation with the straight pliers, and all the anterior and 
lateral ones, with the curved pliers; making attempts, from time to 
time, to draw the head down, as he finds reason to believe that it is 
sufficiently broken up. Such are my views of the mode that ought 
to be adopted. I, at least, am fully of opinion that Mrs. R, could 
not have been rescued by me, had I relied only upon the crotchet for 
her delivery: w T ith my embryotomy forceps, I should not hesitate to 
promise to deliver speedily in a pelvis of two inches. 

It is proper to observe, that the female constitution suffers less in 
the first hours of labor, in which the head cannot engage, than in those 
wherein the head sinks low into the excavation. This depends upon a 
well known principle, namely, that the contractions of the womb are 
violent and powerful in proportion as that organ becomes smaller or 
more condensed. If the head becomes arrested in the excavation, and 
particularly after having escaped from the uterine cavity, it is urged 
with great power upon the tissues, which resist its further descent. 
Under such circumstances, constitutional irritation is rapidly deve- 
loped; whereas, under the more lenient exertions of the uterus, w 7 hile 
the entire fcetus is contained within its cavity, not only is the impul- 
sion of the head against the resisting tissues far more moderate, but 
in the intervals of the pains no pressure exists. Hence a woman 
remains long in labor, with little constitutional disturbance, in the 
kind of cases I am discussing. These observations are illustrated, 
and their truth confirmed, by reference to some of the most celebrated 
examples of such labors, which are recorded in the books. 

Whenever, therefore, a woman has fallen in labor, who is known 
34 



530 MEIGS* EMBRYOTOMY INSTRUMENTS. 

to have an impracticable pelvis, and in whom the Caesarian operation 
is rejected — if the perforator is to be resorted to, it should be applied 
as soon as possible, in order that, the child having ceased to exist, all 
the facilities derivable from incipient decomposition of the foetus may 
be enjoyed. Twenty-four hours after the death of the foetus, the firm- 
ness and cohesion of its soft parts are so much lessened by maceration 
in an elevated temperature, equal probably to 99°, that the extraction 
of the pieces of bone becomes exceedingly easy. I should, therefore, 
in such difficult cases, recommend that all attempts to deliver should 
be delayed, if possible, for twenty-four hours after the perforation of 
the head. This recommendation is founded on what I have experi- 
enced of difficulty in getting out the portions of bone after I had 
broken them up, when I made the attempt antecedently to the occur- 
rence of signs of decomposition. The patient can be quieted with 
anodynes, and supported with light nourishment, and, if needful, may, 
by venesection and cold drinks, be kept tolerably free from vascular 
disturbance during the whole period of such delay as may be deemed 
advisable. 

The engraving, Fig. 108, shows the form of the perforator that I 
employed in Mrs. R.'s case. It is a trocar or drill, ten inches in 
length from the handle to the point. I was obliged to make use of 
such means of penetrating the skull, since no suture w T as practicable, 
and the common Smellie's scissors could not be made to perforate the 
solid bone, any direct pressure causing the head to roll, or move up- 
wards, and any rotatory or drill-like motion with it, being impossible 
without great danger of wounding the lips of the os uteri. The same 
cut exhibits both the straight and curved pliers. They are eleven 
inches in length; the gripe is serrated, and the sides of the mandibles 
are rounded, in order that they may not pinch any tissues except those 
intended to be included in the bite, w T hich, on account of the serrae, 
is very sure and strong. 

I learned, after the events above described, that this patient again 
became pregnant, that the child presented the breech, which would 
make delivery per vias naturales absolutely impossible, that she was 
under the care of Dr. Nancrede of this city, and was safely delivered 
of a living child, by means of the Caesarean operation, performed by 
Professor Gibson of the University of Pennsylvania, assisted by the 
late Dr. Beattie, Dr. Nancrede and others. In a subsequent or fourth 
pregnancy I saw her, the history of which case was again drawn up 
and given to the public, in the American Journal of the Medical Sci- 
ences, by Dr. George Fox, to whom I am indebted for the relation 



MRS. R.'s CASE. CESAREAN OPERATION. 531 

already above given to my readers, and from whose interesting "Ac- 
count of a Case in which the Ccesarean Section, performed by Dr. Gib- 
son, was a second time successful in saving both mother and child," I 
take a portion, with a view to make it more extensively known by 
means of this volume. 

As Dr. Fox's paper is partly occupied with the preceding histories, 
I shall commence at p. 17 of his statement. 

" Toward the latter end of August last, Mrs. R. called on me, and 
stated she had nearly completed the seventh month of pregnancy, and 
was desirous that I should again attend her; this I agreed to, upon 
condition that she would consent to the performance of any operation 
which should be deemed most advisable. Dr. Meigs kindly consented 
to attend with me. 

" Premature labor, in her then advanced state of pregnancy, we 
considered would be attended with as much difficulty, and much 
greater danger to the patient, than at the full period. 

" Under the impression that the Cesarean section would be most 
proper, we endeavored to prepare her system for this operation, should 
it be concluded upon, by a regulated diet, such as would be least 
stimulating, attention to her bowels, &c. : accordingly, for some weeks 
previous to labor, her diet was restricted chiefly to milk and farinaceous 
articles. 

" On Sunday, November 5th, 1837, 1 was sent for by Mrs. R. about 
five o'clock A.M. On my way to her house I stopped for Dr. Meigs. 
We found her laboring under a good deal of mental excitement, with 
a pulse of 116; countenance anxious and pallid; and apparently in 
a much more unfavorable situation than in either her first or second 
accouchement. Her pains had commenced about three hours previous 
to calling upon us; they were slight, recurring at an interval of about 
ten minutes; upon an examination per vaginam, the os uteri was 
found pretty well dilated, swollen, and succulent, as in previous la- 
bors ; the head presenting to the left side of the pelvis ; the membranes 
had been ruptured. Upon inquiry we learned that on the evening of 
the Friday previous there had been a considerable discharge of water 
from the vagina, which continued throughout the following day; but 
as it was unattended with pain, she had not thought it requisite to 
send for us: this discharge was not produced by any exertion on her 
part. After remaining with her some time, finding that her pains 
were not urgent, we concluded to meet at nine o'clock, and invite 
Professors Gibson and Hodge to join us in consultation. 

" 9 A. M. Met Drs. Meigs, Gibson, and Hodge. We found our 



532 MRS. R.'s CASE. — CESAREAN OPERATION. 

patient much the same as when we left her, excepting that the pains 
were rather more urgent and frequent. Upon an examination of the 
case in all its bearings, we determined to advise the Csesarean section, 
as best under the circumstances. I accordingly stated to the patient 
our views of her case, and after some little hesitation obtained her 
consent to the performance of this operation ; previous to which, upon 
an examination of the abdomen, we were struck with the complete 
anteversion of the uterus; the old cicatrix was dark-colored, hard, and 
puckered, about five inches in extent ; adhesion had apparently united 
the integuments and uterus for a space of four or five inches, from 
near the pubis up towards the umbilicus. 

"We now ascertained, by applying the ear to the uterine region, 
that the child was living. Our patient's bowels having been opened 
by an enema, and her bladder emptied, she was placed upon a table 
protected by a matress, on her back, with her hips at the edge, and the 
operation immediately performed by Dr. Gibson, in the presence of 
Drs. Meigs, Hodge, Norris, C. Bell Gibson, and myself. Dr. Norris 
and myself making firm pressure upon the sides of the abdomen to 
prevent protrusion of the intestines, Dr. Gibson commenced by making 
his incision with a scalpel, through the integuments, muscles, &c, 
extending from an inch and a half below the umbilicus, nearly down 
to the pubis, directly through the old cicatrix; the uterus was found 
connected with the integuments by strong adhesions, for a space of 
about four inches ; the incision into this organ was made near the 
fundus, and extended down five or six inches; that portion which was 
adherent was much attenuated, being scarcely one-fourth of an inch 
in thickness. To ascertain the extent of these adhesions, Dr. Gibson 
with his scalpel dissected up the integuments on one side, until a 
knuckle of intestine protruding satisfied him of their extent, which 
might be about half an inch. 

"When the section of the uterus was completed, the placenta was 
seen immediately under the line of incision, and partially detached 
by the separation of the lips of the wound. Dr. Meigs, standing on 
the left of the patient, now introduced his left hand towards the right 
side of the womb, displacing the placenta no more than was necessary 
during the exploration, yet detaching a considerable portion of it, as 
it filled the wound in the organ; he first extricated the left foot and 
hand, which were found near each other ; the breech soon followed, 
succeeded immediately by the shoulders, and lastly by the head, after 
a few moments of resistance, by the contracting edges of the cut, which 
grasped the neck of the child, and the hand of the operator, with great 



MRS. R. S CASE. CESAREAN OPERATION. 533 

force. The placenta was soon after removed through the incision, 
and the cord tied and cut ; the hemorrhage from the uterus was at first 
considerable, but ceased upon the contraction of that organ, after the 
removal of the child and placenta. The external wound was brought 
together by six sutures (introduced from within outward), and adhe- 
sive strips, and a compress placed over it ; a broad band, to support 
the abdomen, was now applied around it ; the pressure of its sides, 
to prevent protrusion of the intestines, was continued until the exter- 
nal wound was closed. 

"The child thus born was a boy of good size, but in an extremely 
feeble state: some time elapsed before perfect respiration was estab- 
lished, but happily the efforts of Dr. Meigs were completely success- 
ful, and all anxiety on its account ceased. 

"Our patient bore the operation well, scarcely murmuring; in fact, 
she says, she suffered but little more than with one labour pain, her 
pains usually being uncommonly severe. Her position was not altered, 
excepting that her lower limbs were now supported by another table. 
Her pulse immediately after the operation was 96, just before 112. 
She is enjoined to lie perfectly still, not on any account to move ; to 
be permitted to take nothing but small portions of barley water; and, 
in case there is much pain, a teaspoonful of the following: R. Sulph. 
morphias, gr. ij ; aquae, £i. M. ft. sol. 

" Soon after the operation, Messrs. J. Forsyth Meigs and Skelton 
arrived ; these gentlemen assiduously devoted themselves to our patient 
during the first five days and nights, so that had any unfavorable 
symptom appeared we should have had immediate notice. 

" 1 \ P. M. Feels quite comfortable ; after pains very slight ; 
pulse 80. 

"4 P. M. Pulse 88 ; has taken one teaspoonful of morphia solu- 
tion. 10 P.M. Met Dr. Meigs. Pulse 88; skin pleasant; gentle 
moisture; tongue clean and moist; some flatulence; not much sore- 
ness ; after pains moderate ; urine drawn off by the catheter, six ounces ; 
directed solut. morphise to be given every three hours if there is much 
pain, and a small portion of lime water occasionally for the flatulence. 

"6th, 10J A. M. Met Drs. Meigs, Gibson, and Hodge. Mrs. R. 
passed a restless uneasy night ; was unable to sleep, though not in 
pain; took a dose of morphia at 11 \ P. M., and another at 5 A. M., 
also lime water twice. Her pulse is 85 and soft ; skin pleasant ; slight 
distension of abdomen, without any increase of soreness; urine by 
catheter five ounces, of natural appearance. \\ P. M. Symptoms 
all favorable ; pulse 88. 4 P. M. Pulse 92. 8J- P. M. Met Dr. 



534 MRS. R.'s CASE. — CESAREAN OPERATION. 

Meigs. Pulse 94 ; skin and tongue moist and pleasant ; countenance 
good ; no expression of anxiety ; considerable tympanitis ; complains 
much of flatulence ; no after pains ; lochia free and natural ; urine by 
catheter ten ounces. At this time a catheter was introduced into the 
rectum, which caused the discharge of a large quantity of gas, render- 
ing her much easier, and completely relieving the tympanitis. Directed 
a tablespoonful of the following mixture to be given every two or three 
hours: R. Bicarb, potassae, 5ij ; sulph. morphiae, gr. ss ; aquae 
menthae, p. §vj. M. ft. sol. 

"7th, 10 A.M. MetDrs. Meigs and Gibson. Our patient had 
a very good night ; slept comfortably, without an opiate ; pulse 78 and 
soft ; countenance good ; respiration natural ; skin pleasant ; tongue 
slightly furred, but moist ; urine by catheter eight ounces. 4 P. M. 
Pulse 82 ; no pain or tenderness ; has slept through the day; expresses 
herself as feeling comfortable. 8J P. M. Pulse 84 ; no return of 
tympanitis since the introduction of the catheter into the rectum last 
evening; urine by catheter eight ounces; continued mixture. 

" 8th, 10 A. M. Rested well all night ; secretion of milk natural ; 
the infant was put to the breast during the night; pulse 100; skin 
pleasant, moist; tongue slightly furred, moist; urine by catheter eight 
ounces ; wound was examined without removing dressings ; suppura- 
tion is commencing ; there has been throughout a slight oozing of bloody 
serum ; she is this morning removed to another bed. 2 P. M. Pulse 
92 ; secretion of milk increased so much as to cause some uneasiness 
to her ; breasts are directed to be well drawn. 8J- P. M. Pulse 92 ; 
breasts relieved by drawing ; urine by catheter ten ounces. 

" 9th, 10 A. M. Slept soundly all night ; appears very comfort- 
able ; pulse 97; skin pleasant, moist; secretion of milk abundant, 
lochia natural ; urine by catheter eight ounces. 6 P. M. Pulse 96 ; 
skin moist ; abdomen flaccid, free from all pain or tenderness ; no 
flatulence ; urine by catheter eight ounces; directed the mixture carb. 
potassae to be omitted ; she had taken it occasionally, on account of 
flatulence, since the evening of the 6th; to-night, is permitted to take 
arrowroot gruel ; has been restricted to small portions of barley water 
until this time. 

" 10th, 9 A. M. Slept comfortably ; having some return of flatu- 
lence, took two doses of potash mixture in the course of the night ; 
relished gruel ; external organs were washed with weak wine and 
water, much to her relief; pulse 104; skin moist; urine by catheter 
eight ounces. 1 P.M. Pulse 100; wound dressed for the first time; 



535 

it extends from half an inch above the pubis to one and a half inches 
from the umbilicus ; adhesion has taken place at the upper and lower 
ends; discharge slight, bloody, dark-colored; at the upper end of the 
cicatrix from former operation, on the right side of the incision, it is 
slightly inflamed, of an erysipelatous appearance, and ulcerated, for 
the space of two inches ; I removed a stitch from this point, which 
seemed to be a source of irritation, also one from the upper end ; 
washed the parts and applied fresh adhesive strips, leaving a sufficient 
space for the free escape of pus; a piece of lint, spread with cerate, 
and bandages were then applied ; she complained of no pain or fatigue. 
Bowels not having been moved since the operation, an enema of warm 
flaxseed mucilage is directed ; breasts, which are somewhat trouble- 
some, to be well drawn ; the child would nurse, but from the mother's 
position it is difficult and fatiguing ; consequently, we rarely put it to 
the breast, having from the first had a wet nurse for it. 6 P. M. 
Pulse 100 ; skin pleasant ; no pain ; all her symptoms are most favor- 
able; urine by catheter ten ounces; enema not having operated, 
another to be administered. 

" 11th, 9 J A. M. Slept well, but in consequence of some pain in 
the evening, caused by the enema (which operated freely), she took 
two doses of morphia solution; pulse 96; tongue less furred, moist; 
urine by catheter eight ounces; abundant secretion of milk; no un- 
favorable symptom; slight dark-colored discharge from wound; fresh 
cerate applied; asks for increased diet ; is to be allowed the soft part 
of six oysters and a biscuit, in addition to the gruel. 6 P. M. Pulse 
96 ; urine by catheter six ounces. 

" 12th, 10 A. M. Rested well; took one dose of morphia; pulse 
98 ; skin pleasant ; has passed water twice through the night without 
the catheter; the wound looks well, healing; inflammation about the 
old cicatrix much diminished ; I removed three more stitches, and ap- 
plied fresh adhesive strips to lower parts of it; diet, milk, eggs, and 
oysters. 

u 13th, 10 A. M. Pulse 96; no pain; skin natural; tongue clean; 
slept well; wound looks well; removed the last suture, and applied 
fresh dressings. 

" 15th, 10 A. M. Has slept w T ell for the last two nights; pulse 96, 
soft and pleasant; skin and tongue natural; countenance good; very 
cheerful ; spirits throughout have been excellent. Wound looks well ; 
adhesion perfect above and below; is filling up rapidly; inflamma- 
tion of right edge subsided ; suppuration moderate, lighter color ; 



536 

lochial discharge has ceased. This morning, for the first time, she 
complains of her position, which has been altogether upon her back; 
upon examination, a small slough (size of a cent) is discovered upon 
the sacrum; inquiry had frequently been made upon this point, but 
the fear of being moved induced her to conceal the pain and sore- 
ness until this time ; her position is now changed to the side, hips 
being protected by adhesive plaster; a poultice of bread and milk to be 
applied to slough; diet as before. 5J- P. M. Much more easy since 
change of position ; pulse 92; has for the last two days suckled her 
infant. 

" 17th, 10 A. M. Pulse 84; bowels were opened yesterday by an 
enema; slough separating, superficial, does not complain of it; wound 
looks healthy ; suppuration slight. 

"25th. Has been very comfortable since last report; no pain or 
tenderness; pulse 88; wound nearly closed, a small opening merely 
remaining about the top of the old cicatrix; the discharge from it 
very slight ; bowels being confined, she is requested to take ol. ricini 
E} ; to-day is permitted to sit up in the bed. 

" We have conceived it unnecessary to head each daily report, 
'Met Drs. Meigs and Gibson,' we having continued to meet regu- 
larly during the first week; after which time, Dr. Gibson saw her 
occasionally, during the progress of the case, as convenience or incli- 
nation dictated ; Dr. Meigs continued in regular attendance some time 
longer. 

"December 26th. Mrs. R. has continued perfectly well; soon 
after date of last report was permitted to leave her bed ; the slough 
on the back soon separated and caused but little inconvenience; the 
incision in the abdomen has healed, with the exception of a small 
fistulous opening, which is occasionally touched with lunar caustic ; 
her diet has for some time past been generous. 

" February 21st, 1838. The fistulous opening heretofore noticed 
continued a source of annoyance till the 10th inst., since which time 
it has been entirely closed ; the cicatrix is now complete, and looks 
healthy. 

" Remarks. — Our patient had a better ' getting up* than many 
females after an ordinary accouchement; her sufferings after the ope- 
ration, were slight indeed ; in twenty days from the day of its perform- 
ance, she sat up; and for some days previous, constantly nursed 
her infant. The adhesions connecting the uterus and abdominal 
parietes in front were so extensive, as almost to have permitted the 



MRS. R.'s CASE. CESAREAN OPERATION. 537 

performance of the operation, without necessarily opening the peri- 
toneal sac ; very much diminishing its dangers. It may be worthy 
of notice, that nine months subsequent to the former operation, during 
lactation, the menstrual discharge returned, healthy and natural in 
every respect. During the progress of the case, the patient was visit- 
ed by many of our medical friends. 

" The infant has grown finely, not having had an hour's sickness 
since birth." 



538 INDUCTION OF LABOR. 



CHAPTER XVII 



INDUCTION OF PREMATURE LABOR. 



In cases of deformed pelvis in which the reduction of the diameters 
has not gone too far, the child may be rescued, if it be delivered at 
a period between the attainment of its viability and the completion 
of term, if the development of it shall not have rendered it too large 
to pass through the contracted passages. 

The foetus in utero is understood to be viable or livable at the com- 
pletion of the seventh month ; at that period the foetal characters of 
the heart have begun to approach towards those of the respiring child, 
and the pulmonary vesicles have become so thoroughly developed, 
that most of the children born at that term are free from the danger 
of atelectasis pulmonum. For a woman with a bad pelvis — with a 
pelvis reduced, for instance, to three inches in its diameter — it is very 
good fortune to be prematurely delivered, if the uterine gestation have 
not gone beyond the eighth month; for the head of the child at that 
time is both small and very ductile. The observation of cases in 
which women with deformed pelves have given premature birth to 
living children, led at length to the adoption of operations by means 
of which the child is ushered into the light, at times supposed to be 
so well chosen, that the disproportion between the foetal head and the 
contracted pelvis should not render its escape impossible. 

Dr. Denman in the tenth section of his twelfth chapter, treats of 
the propriety of bringing on premature labor, and the advantage to 
be derived from it. The first information which he obtained upon 
the subject was derived from Dr. C. Kelly, who informed him that 
about the year 1750, there was a consultation of the most eminent 
men in London at that time, to consider of the moral rectitude and 
the advantage to be expected from the practice ; which, it appears, 
met the general approbation. The first case in which it was necessary 
and proper, was terminated successfully by Dr. Macauley. Dr. Ma- 
cauley had performed it several times, and sometimes with success, 



INDUCTION OF LABOR. 539 

and Dr. Denman relates the case of a lady of rank whom he attended 
with Dr. Savage, in consultation, in which the operation proved suc- 
cessful. 

Dr. Lee, in his Clinical Midwifery, 2d ed. p. 81, relates the history 
of the operation in the labor of Mrs. Ryan, set. twenty-one, primipara. 
— She lost the child after an embryotomy operation. In her second 
labor, Dr. Lee opened the membranes at the eighth month : he per- 
forated the head. The third labor was brought on at seven months 
and a half, the feet presented ; child lost. Fourth labor, induced at 
seven months, footling ; child dead. Fifth labor, induced at the 
seventh month ; the child, born alive, died in sixteen days in convul- 
sions. Seventh labor, induced at seven months and a half, the feet 
presented; child lost, great force required. Eighth labor, induced at 
seven months and a half: feet presented, child dead. Ninth labor, 
induced at the seventh month, the feet presented, child lost. Tenth 
labor, membranes perforated at the seventh month: child lost. Ele- 
venth labor, induced at the end of the sixth month: child dead. 
Twelfth labor, induced in the seventh month: child dead. Thirteenth 
labor, at the end of the sixth month labor induced: child lost. Four- 
teenth labor, seventh month: child extracted alive, but soon died. 
Fifteenth labor, seventh month : child lost. I have cited this case of 
extraordinary perseverance, on the part of Dr. Lee, as much to show 
the resolute energy of that gentleman, as to show what may be ex- 
pected in many of the cases of induction of premature labor. 

It is not to be doubted that the operation is legitimate, and that he 
who does it properly acts within professional rules and usages; but, 
inasmuch as every premature labor furnishes some just grounds of 
apprehension, both for the parent and child, I am very clear in the 
belief, that well understood motives alone can justify the accoucheur 
who performs it. A woman may lose her child in labor, and so on 
throughout a succession of labors, from faults not at all relative to the 
state of the pelvis. A lady was under my care in this city, w T ho, in 
sixteen pregnancies, had given birth to only one living child; she then 
gave birth to two children, of which the first was born a little past 
the eighth month, whereas the gestation of the last son continued until 
the close of the ninth month. There was never suspicion of the least 
fault in the dimensions of the pelvis. A lady of this city, out of 
eight children lost seven in labor. It was proposed to her, previous 
to the birth of her ninth and last child, to submit to the induction of 
premature labor. I had been long convinced that the cause of the 
death of the children, in this person, was a cause relative to the action 



540 INDUCTION OF LABOR. 

of the uterus, and not to the resistance of the pelvis; for children, 
the transverse diameter of whose heads amounted to full four inches, 
had been expelled, or drawn through it with the forceps. I had al- 
ways maintained that the loss of the children was occasioned by the 
preternatural energy of the uterine contractions, which, from the be- 
ginning to the end of the parturient effort, were of a character de- 
serving truly to be called ergotic ; the contractions of the uterus were 
permanent, and, as the children were large, the placental circulation 
was always suspended by the pressure of the afterbirth against the 
trunk of the child's body, so that when born, it was born dead from 
asphyxia. 

The deep interest which I took in the misfortunes of the parents, 
thus deprived of the comfort and hope of offspring, did not prevent 
me from resisting the proposition to bring on labor prematurely, and I 
felt prompted, from a desire I had to explain myself to the gentleman 
interested, to address to him a letter, of which the following is a copy, 
and which I publish here w T ith a view to send it forth, not as an argu- 
ment against the induction in cases suitable for it, but as a caution 
to such as might feel tempted, unnecessarily, to resort to this method 
of saving the child. 

The following is the letter which I addressed to the gentleman in- 
terested, who, being himself a physician, had assisted at the very large 
consultation of physicians summoned for the purpose of deciding the 
question as to the induction of premature labor in the case. 

Thursday, August 11th, 1843. 

My Dear E., 

As you appeared yesterday to be at a loss to decide upon the steps 
proper to be taken in the approaching crisis, and as I suppose rather 
inclined in favor of the operation for the induction of premature labor, 
I think I shall feel better satisfied if I lay before you in writing the 
reasons which compel me to entertain an opinion perhaps wholly con- 
trary to your own sentiments and wishes, yet maintained, as I think, 
for your real interest and happiness. I prefer that you should have 
this written statement both for your own greater satisfaction and also 
in order that I may not be at all misunderstood. Opinions thus de- 
liberately expressed and defended, are safer than those delivered viva 
voce. 

I am sure that you already know that I approve of the operation for 
inducing premature labor, in all cases where it is not performed too 
early to admit of the viability of the child, and where the withholding 



INDUCTION OF LABOR. 541 

of it altogether, involves the mother in the certain necessity and risk 
of a severe embryotomy operation. 

If the antero-posterior diameter of the upper strait is below 3J inches, 
there is always the greatest probability that embryotomic instruments 
will be required ; I say the greatest probability, for it is certain that 
children have been born without their aid in cases of pelvic deformity 
even greater than this. Such a deformity then, if it does not go too 
low would warrant the operation, and recommend it as an act of pro- 
fessional duty. Now my opinion on this point is, I hope, very clear. 
But where the pelvis is of such magnitude as to admit of the transit 
of the foetal head, and further renders the application of the forceps 
practicable, I hold that no man would be justified in inducing prema- 
ture labor, without exigent necessity arising out of some well under- 
stood, highly probable peril of the mother herself. 

In the case in question we have seen delivery effected in a labor of 
four hours with a foetal head of dimensions which may, without exag- 
geration, be termed enormous — for a head of four and a quarter inches in 
the bi-parietal diameter is equal to the largest head I have ever seen at 
birth — and is just nine-twentieths of an inch above the average mag- 
nitude. 

The history of the past labors shows that the difficulty does not 
depend upon the smallness of the pelvis, either actual or relative. The 
history of hundreds of labors issuing happily, will show that the fcetus 
can bear longer and severer pressure of its cranium than ever has been 
borne in our case. In fact the history of these labors, as I know that 
history, shows that the evil has been in the uterus and not in the 
pelvis. This perhaps you may not admit. 

Peradventure a premature labor might be marked by a character 
of uterine action different from those that have fallen at term. But 
shall a man feel justified to enter on an important operation, one ad- 
mitted to be dangerous to the mother and uncertain for the child in 
the proportion of 50 per cent., upon the ground of a mere peradven- 
ture ? I cannot think so. 

I am not much accustomed in my medical transactions to be guided 
by what are called authorities. In the first place every case of dis- 
ease, and every case of surgical disorder or accident, is a speciality. 
The action upon each case should be determined by judgment held 
upon the case, and not upon reported cases. Besides I conceive 
myself to be capable, after the clinical experience I have had, of judg- 
ing for myself; of making up my own opinion of what is my duty in 
every instance of disease submitted for my opinion. Were I, however, 



542 INDUCTION OF LABOR. 

very readily inclined to follow the masters, I know not where I should 
look to find an authority for this operation. The only one that has 
the least resemblance of favoring it is that of Denman, who twice in- 
duced a premature labor successfully for women who had previously 
lost their fruit in utero in the seventh month. The cases, you see, are 
not parallel, and if they were I should not be moved by them, for I 
have seen a woman lose four children in successive pregnancies, from 
the sixth (or fifth) to the seventh month, who yet bore children after- 
wards at the full term, and in good health. Dr. Denman's patient 
might have done likewise, and I think he was not justified even by 
his good fortune in the dangerous operation he performed ; I think he 
acted like a rash and injudicious man, whose success is no palliation 
of his error. 

To force or invite the womb to enter into action before term, is to 
do violence to the organ by a voluntary interference with the law of 
its organism. It is a rule universally accepted that we must not do 
violence to the womb, except upon urgent necessity; I adopt and 
teach this rule, and I can never feel myself justified in recommend- 
ing such action unless I can have very clear perception of the neces- 
sity for it, as relative both to the mother and fetus. So it is pretended 
that such exigency exists in relation to your lady. 

I believe you have taken too flattering a view of the operation even 
as it relates to the child itself. 

A child is esteemed to be viable at the end of the seventh month. 
It is, I say, esteemed as viable, yet the facts show that a very large 
proportion of seven months children fail to live long. Indeed it is 
understood that fifty per cent, of the whole sum of human progeny 
is lost at the end of the sixth year after birth, and how much greater 
the percentage in the cases of premature parturition. 

If you will examine the results of the operation in Dr. Churchill, 
you will observe that he states in all 945 cases of the induction; I 
suppose that many of the 945 cases are restatements, i. e. they are 
cases stated over and over again, but admitting that there have been 
945 operations in fact, we still find that only 536 children lived. 
Lived, I say, but no man knows how long; and it is not uncharitable 
to say that if we knew the whole truth we should be obliged to make 
a very large subtraction from the number of 536. I have not the least 
belief that near one-half have been saved! and it is admitted that 
many of the operations were unnecessary and even preposterous. 

Dr. Chailley tells us that of the 211 cases collected by Stoltz though 
more than one-half of the children were living, one in fifteen of the 



INDUCTION OF LABOR, 543 

women died. Such a result proclaims the operation to be dangerous. 
It is true that we cannot here decide as to the difficulties and dangers 
of these 211 cases, and it may be true that the operation is less dan- 
gerous for a woman with an ample pelvis than for her who has a de- 
formed one, and that in our own case the danger would be less on 
account of the known capacity of the organ. Be it so — but the argu- 
ment is a felo de se, for it goes to show that it is not demanded by 
Mrs. E., but only by the child. 

Has the child claims? Yes! but the claims of the mother are 
paramount. Is it demanded as referable to the gratification of an 
anxious desire to have a living offspring? That is a holy and righteous 
desire, God grant it may be satisfied, but the function of the surgeon 
and accoucheur appertains to the health of the patient; the happiness 
of the patient is the gift of God. The surgeon cannot lift the veil of 
the future, and if he could he would perhaps be even more reserved 
than he is now as to the institution of attempts, whose object goes 
beyond his true vocation. Let him adhere to his vocation, which is 
fulfilled when he preserves or restores the health of his clients. The 
mother is his client in the paramount degree. 

Let us essay to set in order some of the reasons for waiting until 
labor shall begin spontaneously in this case. 

1. She has given birth to one living child. 

2. She has had one unassisted delivery. 

3. She has had children of enormous magnitude. 

4. There is great reason to suppose, even if it be not absolutely 
true (as I believe) that the fault is in the nature of the uterine fibre, 
and not in the form or dimension of the pelvis. If so, then no opera- 
tion is admissible. 

5. She has recovered well. 

6. She has been delivered of a child beyond the average size, in a 
labor of only four hours. 

7. No man knows whether the child now in utero is above the 
average size. 

8. If there is a breech, knee, or shoulder presentation, what should 
we gain by a violence done both to the mother by the operation, and 
to the child by hurrying it into the struggle before it is completely 
developed and prepared for the strife. 

9. Who knows if it be or be not a twin pregnancy? if it be a twin 
pregnancy, what vain, what poignant regrets over a step signally 
false!! 



544 INDUCTION OF LABOR. 

10. Possibly she may spontaneously enter on labor at eight months 
and a half. 

11. Do we know that it has not already a prolapsed cord ? 

12. Suppose the operation done and the lady attacked with the 
chill so common in the case — suppose her the victim of a metritis — 
with a living orphan child? cui bono! 

But, my dear E., I will not continue to string together objections; 
they are all comprised in the single fact that she is a fit subject for a 
forceps operation, if that should be demanded by the circumstances. 
This fact is an unanswerable one in my estimation. It is true I could 
set forth reasons of a moral complexion for refusing intervention, but 
I shall refrain considering them, as equally obvious to you and to me. 
I pray you, however, in this matter, not to misapprehend me; I have 
no doubt of the morality of the induction; nor of our legal right to do 
it, under the diploma given by the authority of a state. I look upon 
that diploma as an authority given to me by state commissioners, and 
in the name of the state, constituting me judge, to act at my peril 
under the indications of an upright and enlightened conscience, and 
judgment. But the spirit of my commission is caveat as to all rash- 
ness and irregularity of proceeding. 

I hope the effect of this letter may be to lead you to submit with 
readiness to the voice or will of the consultation, which was not given 
in favor of the induction. We admit we do not know, and no man 
can know, what the result will be, but I trust you will believe that 
should it be fortunate I shall greatly rejoice in your mutual happiness: 
if it should be unhappy again, I shall sympathize in your distress. 
I shall in any event steadily adhere to this, viz. : that it is better to 
suffer the ills that Providence sends for our chastisement, than by rash 
and ignorant measures of precaution against them, make them tenfold 
more intolerable. 

I am, &c, 



The following notes were furnished to me by my friend, who was 
present at the birth of the ninth child. The history of the labor and 
the measurements of the foetus, as well as its weight, serve, I think, 
fully to confirm my opinions in opposition to the proposed operation 
in the case. 



INDUCTION OF LABOR. 545 



NINTH ACCOUCHEMENT. 



August 29, 1843. — Eight months and one quarter {or one-third at 
most) of utero-gestation. 

Labor commenced about seven P. M., a short time before reaching 
home after a long ride. Quarter past seven. — Reached home, and 
went immediately to bed ; pains recurring, at intervals often or fifteen 
minutes, until eight o'clock, when they became more frequent and of 
shorter duration. 

8J P. M. — Dr. Hodge arrived ; found os uteri size of half a dollar. 
; 9 P.M. — Vs. 3xxv ; Dr. Meigs arrived during the operation. 

20 minutes past nine. — Gave 40 grs. Dover's Powder by enema. 

45 minutes past nine. — Gave 35 drops laudanum, by mouth. 

50 minute's past nine. — Pains recurring ; membranes protruding ; 
os uteri fully dilated. 

55 minutes past nine. — Pains on and off; intermitting; uterus re- 
laxes after pain, which is unusual in her case. 

10 P. M. — Pains every few minutes. 

10 minutes past ten. — Cramps in left leg during pain. 

20 minutes past ten. — Anodyne effects decided; patient complains 
of feeling sleepy ; pains continuing regular and natural until 

5 minutes before eleven — when a strong pain came on, with bear- 
ing-down efforts. 

IIP. M. — Good pain ; head descending rapidly; membranes rup- 
tured. 

5 minutes past eleven. — Child born ; no accident or artificial inter- 
ference ; weight seven and one quarter pounds, dressed. — Male. 

Bi-parietal diameter 3 T 6 ^. 
Occipitofrontal 4j%. 
Head 'j « -mental 6A 
i Bi-temporal 3. 



1 0' 



35 



546 INTER SI ON. 



CHAPTER XVIII 



INVERSION OF THE WOMB, 



Inversion of the womb is that state in which the uterus becomes 
turned inside out. Inversion is incomplete or complete. When it is 
incomplete, the vault or concave of the fundus has fallen down into 
the cavity of the body, of the neck or the vagina cf which it may 
occupy the upper extremity. 

When inversion is complete, the vault of the fundus has come 
quite out through the os uteri, followed by the corpus and the cervix. 
In this case the womb is inside out, as a stocking is that has been 
turned inside out in drawing it off the foot. 

The accident is a rare one. Yet the consequences of it are so 
terrible, that the accoucheur ought not in his practice to lose sight 
of the possibility of its occurrence, nor fail ro guard his patient 
against it. 

When the womb remains relaxed or uncontracted after the delivery 
of the child, no attempt ought to be made to take away the after-birth 
by pulling at the navel string. Should the placenta be still adherent 
to the fundus uteri, any tractions exerted on the cord would tend to 
draw forth the after-birth, which might, perhaps, drag the fundus uteri 
along with it, and thus turn the organ inside out, or invert it. Inver- 
sion of the womb is one of the most dangerous accidents that can 
happen to a lying-in woman; it is always attended with severe pain, 
and the most violent hemorrhage ; and, if not early remedied, becomes 
soon irremediable, since it would be as easy to turn a non-gravid 
womb inside out as to restore forcibly an inverted one, when many 
days or hours have elapsed after the occurrence of the inversion. 

Those who have had the hand in utero, in turning, can well appre- 
ciate the exceeding laxity of the womb when not affected with the 
pains; they can readily conceive that the mere weight of the after- 
birth, still attached to the fundus, might, were the woman standing 
upon her feet, cause a commencement of inversion, which could be- 



INVERSION. 547 

come complete by means of the woman's strong voluntary efforts to 
bear down her pains. It is not to be doubted, that instances of inver- 
sion have occurred in which the practitioner deserved no further blame 
than that of not taking the proper precautions against its occurrence, 
by commanding the patient to preserve the horizontal posture, and 
abstain from all bearing-down efforts. 

Notwithstanding the occurrence might take place spontaneously, 
and immediately after the birth of the child, yet, in a major part of 
the examples, it has been produced by an improper haste and impa- 
tience to get away the after-birth. 

I have seen but three persons who have had inversio uteri, and 
they are recovered; one, Mrs. S., w T as already the mother of tw T o 
children when she again became pregnant of the child born in June, 
1831. 

It seems that, having, on both the preceding occasions, suffered 
severely from the method adopted by the physician in removing the 
after-birth, and supposing that a midwife would deal more gently with 
her, she engaged an old woman, much accustomed, as it was said, to 
the care of women in labor, to attend her upon this occasion. The 
child was born by a very easy labor, but the after-birth not coming 
away so promptly as it w T as desirable, tractions were made upon the 
cordw T hich caused the after-birth to come into the vagina. This gave 
the patient exquisite pain. The midwife, who could not understand 
why the woman should suffer so severely, made haste to draw the 
placenta forth by the cord, which made her cry out so loud that it 
was said her voice w 7 as heard in the street. When the mass came 
away, the good woman found it still adhering to something; she could 
not take it up, and put it into a basin. She therefore continued to pull 
at it w r ith great force, not knowing that she held in her hands the 
after-birth still adhering to the fundus of the womb, which was now 
completely drawn forth and turned inside out. The hemorrhage was 
enormous, and the patient soon sunk into the extremest weakness and 
exhaustion. Half an hour elapsed before she thought proper to con- 
fess her incompetency to manage the case. I w r as sent for, after she 
had acknowledged her ignorance of the method of proceeding, and 
when I arrived, the pati°nt w T as without pulse, very cold, suffering the 
extremest distress, with constant jactitation, and a thirst that was 
unappeasable. To all appearance the woman was in the agonies of 
death. I found the globe of the womb hanging down full half w T ay 
to the knees, and still invested with the placenta and membranes, 



548 INVERSION. 

except where they had been torn and broken by the attempts of the 
midwife to pull the entire mass away. 

I endeavored to push the whole womb and placenta back into their 
natural position, but finding I could not succeed, I sent for my vene- 
rable friend Dr. James, who speedily arrived. Dr. James now made 
an attempt to reposit the womb, but he also failed. By his advice I 
removed the placenta, but could not force the uterus up into the 
pelvis. 

In making the attempt to restore it to its place, I followed the me- 
thod recommended in the books, that is, I compressed the organ in 
both the hands in order to reduce its size. At last I observed that 
the more I handled it, the firmer and harder it became ; in short, that 
I excited in it the after-pains, just as we excite them by frictions on 
the hypogastrium after the child's birth. I therefore inferred that the 
proper way of proceeding would be to let it rest, and as soon as the 
relaxation of the organ should be complete, as it is in the intervals 
between the ordinary after-pains, to endeavor to indent its fundus^ like 
the bottom of a bottle, and then carry it upwards. I found, upon ob- 
serving it, that the womb repeatedly expanded or relaxed, and then 
contracted again, being soft in the former and hard in the latter state. 
Taking, therefore, the moment of the completest relaxation, I indented 
the fundus with one finger, and, as it became more and more concave, 
I applied each of the fingers in succession, until I found that the pro- 
gress of the fundus inwards was impeded by the os uteri, which, 
although it was completely inverted, yet resisted for some time the 
attempt at reposition. By a resolute perseverance I finally had the 
pleasure to overcome the resistance, and the peritoneal surface of the 
fundus was pushed upwards beyond its os uteri, and at last the womb 
was found to be completely restored to its natural position, but still 
containing my hand, which was now up as high as a little above the 
umbilicus. As no contraction came on immediately, I retained pos- 
session of the cavity of the womb, which I gently excited by moving 
my fingers within it, and finally a contraction came on which I suf- 
fered to push my hand out into the vagina. Upon withdrawing the 
right hand, I felt with the other the womb very firmly contracted in 
the lower belly, and enjoyed the satisfaction of complete success in 
this distressing case. 

I have said nothing of the brandy and volatile alkali that were 
o-iven to the woman to keep her from dying. She took a very large 
quantity of these articles, besides laudanum, before I left her, which 
I was obliged to do in order to attend to another patient; and I feel 



INVERSION. 549 

under great obligations to my friend Dr. George Fox, "who came at 
my request and took charge of Mrs. S. for the remainder of the time 
that she continued ill. Her situation when I gave her up to his care 
was nearly desperate, from anemia; nevertheless, by the administra- 
tion of proper restoratives and the judicious exhibition of stimulants 
during several hours, she rallied, and, in no very long time, recovered 
a good share of health. 

From that period she was, for a long time, not quite regular as to 
the catamenia, which appeared at uncertain periods, and less abund- 
antly than before her dreadful accident. 

Since the occurrence of the above recited events, Mrs. S. has been 
twice safely delivered of healthy children by my friend Dr. Bache. 
It is worthy of remark that the placenta was adherent in these cases 
also ; and Dr. B. was not able to effect the delivery of the after-birth, 
until he had separated it from the womb by the introduction of the 
hand into its cavity. 

I cannot refrain from mentioning here the case related by Mr- 
Charles White, of Manchester, in which he succeeded in restoring an 
inverted womb to its natural state by compressing it and then push- 
ing it up. In his case I am not very sure that the inversion was com- 
plete, since, although he represents the inverted uterus to have been 
as large as a child's head, it was never expelled through the external 
organs, and it is improbable that if fully inverted, it could be retained 
in the excavation. Mr. W. regards his method as of the very highest 
importance, and thinks he should never have succeeded but for the 
compression of the womb in the hand. 

I am ready to admit that it might happen that a tonic contraction 
of an inverted uterus should come on at once, and last so long as to 
prevent the employment of the plan that I suggest; but I think it 
probable that it would always be practicable to return it, in any case 
where it had not been inverted more than four or five hours, by wait- 
ing for the moment of its greatest relaxation, and then first indenting 
the fundus, and afterwards pushing it steadily upwards through the 
os uteri, and so into the abdomen again. 

It has been stated that when the womb is only half inverted, the 
woman is liable to greater pain and danger than where it is turned 
completely inside out, in consequence of the strangulation of the part 
that is griped by the os and cervix uteri. It is thought by some per- 
sons good practice, in such cases, to make, the inversion complete. I 
am unable to speak of this point from any experimental knowledge 



550 



INVERSION. 



that I possess, nor do I know that the probabilities of recovery would 
be greater with a complete than with an incomplete inversion. 

If there be any ground to hope for a spontaneous replacement, as 
I shall hereafter contend, it seems to me that it would be wiser to let 
the incomplete inversion alone, trusting it to the power of nature, rather 
than incur the hazard of wholly inverting it, which would greatly 
lessen the prospect of a future spontaneous cure. 

Of course I am understood as recommending this confidence, or 
rather hope in nature, only for those in whom every reasonable at- 
tempt to restore by the hand has utterly failed and been abandoned. 

A careful and attentive practitioner of midwifery will never fail, 
after the delivery of the placenta, to examine by palpation of the hy- 
pogaster, the state of the uterine globe ; and there can exist but few 
individuals in whom such an examination would not disclose the ab- 
sence of that proper degree of convexity of the fundus uteri, should it 
exist, which is the sure demonstration of the truth that inversion, 
either incipient or complete, has taken place. 

Inversion can only take place by the falling in of the dome of the 
uterus, and such fall is sure to show the upper part of the organ con- 
cave instead of convex, upon palpation of the hypogastric region. 

I delivered a woman some time since who was moribund with he- 
morrhage from placenta prsevia; when I turned the child and brought 
it away by the feet, the womb, which was as flaccid as a wet ox 
bladder, sank inwards, allowing the placenta to come forward to the 
os uteri. I took the placenta away, and the dome of the uterus came 
into the vagina. I pushed it back: it made no resistance, and when 
I withdrew my hand, it followed it again. The patient expired in a 
few minutes. 

I considered her to be dying w 7 hen I reached her bedside. 

The utter flaccidity of this uterus has convinced me that the cases 
reported of spontaneous inversion may be really so, and independ- 
ently of any rash manoeuvres; for the atonicity of the muscular ap- 
paratus may be so complete that the rest of the component tissues of 
the womb can by no means prevent it from becoming inverted under 
the slightest efforts of breathing, of tenesmus, or even of change of 
decubitus. 

I have recently seen a lady whose womb was inverted about two 
years ago at her confinement. I am informed that she had a very 
profuse hemorrhage, and was thought to be in extreme danger. She 
gradually got better, however, but remained subject to frequent at- 
tacks of hemorrhage, by which her strength became greatly reduced. 



INVERSION. 551 

At length a physician whom she called in made an examination, and 
found the womb inverted. In this case the womb hangs into the 
vagina, and is, I think, turned completely inside out; it is not much 
larger than the healthy non-gravid womb — does not appear to be 
very sensible on pressure, but bleeds very easily. By careful regula- 
tion of the diet, strict attention to her bowels, and the use of astring- 
ent injections, under the care of her physician, Dr. Mcehring, the 
hemorrhagic tendencies have of late been happily counteracted, and 
she is acquiring a more decided state of health. She goes freely now 
about the house, and even about the city. This I regard as a very 
consolatory case, as it furnishes additional ground to hope for the 
escape of our patients with life, even where the inversion is incurable. 

Without altering the above paragraph, 1 shall now state, that subse- 
quently to my visits and examinations, this patient was seen and ex- 
amined by Dr. Hodge, Professor of Midwifery in the University of 
Pennsylvania. Dr. Hodge has assured me that he had no doubt of 
the diagnosis, which was an inversio uteri. Dr. J. Warrington, a 
practitioner and lecturer on midwifery, had charge of her after- 
wards, and made the same diagnosis, of the correctness of which he 
entertains no doubt. After her health had greatly improved, she 
manifested symptoms of pregnancy, and proved to be pregnant by 
miscarrying of a foetus of near five months. Here, then, was a case of 
spontaneous replacement of an inverted womb. Of the third case 
that I met with, the following is the recital. 

May 5th, 1841. I this day saw Mrs. S., aged twenty-seven, resid- 
ing in Marshall street. This lady is the mother of two children, the 
youngest of which was born five weeks ago. My friend Dr. Levis, 
who was in attendance and who invited me to the consultation, in- 
formed me that the infant was born some time before he reached the 
house, so rapid was the parturient process. He found the lady lying 
on her back near the edge of the bed — the feet resting upon chairs, 
as if she had scarcely found time to get upon the bed, before the 
eruption of the child, which a woman was holding in her hands in 
order to keep it out of the great pool of blood in which she was bathed. 
The child's head, indeed, was quite born before she got off the pot- 
de-chambre. Upon seeing how great was the hemorrhage, the Dr. 
pressed his hand upon the hypogastrium, and finding the womb strongly 
contracted, he removed the placenta, which he found already in the 
vagina. 

After the delivery, she flooded a good deal, and was very weak; but 
had in a fortnight recovered considerably. After this, she was seized 



552 INVERSION. DR. HATCH'S CASE. 

with flooding of a severe character, since which time she has not been 
free from bloody discharges, which are at times quite copious. 

Two days ago the doctor examined the patient, and found a tumor 
projecting from the os uteri, which he suspected to depend on an in- 
version of the organ. 

The woman is very feeble, and has fits of hysterical delirium fre- 
quently. 

Upon making the taxis, and upon examining by the speculum, the 
tumor so closely resembled the appearance presented by the common 
uterine polypus, that it was difficult, considering its size, resistance, 
color and surface, not to believe that it must be a polypus of the womb 
which had existed throughout the pregnancy, a circumstance hardly 
possible, however, to believe. In order to test the nature of the tumor 
in such a way as to have no shadow of doubt, I introduced half the 
right hand into the vagina, so as to enable me to carry two fingers 
quite far up into the cul-de-sac behind the cervix ; having done this, 
I moved the fingers forwards so near to the upper margin of the pubis, 
that my left hand, laid on the hypogaster, was a very small distance 
from the fingers of the right. They approached so near to each other 
as to render me perfectly sure that no womb was interposed betwixt 
them, and therefore that the tumor below was the womb, and nothing 
else. 

She was informed of the nature of the accident that had befallen 
her, assured of the utter impossibility of any reposition of the organ, 
and comforted with the expectation of a gradual diminution of the 
hemorrhagic tendency, with its final cessation, and recovery of health. 

Directions were given as to rest, diet, topicals, &c, and then, after 
some ten days, she dismissed her medical attendants, to call in Ho- 
moeopathic skill and doses, and, post hoc, sed non propter hoc, she 
gradually got rid of her discharges, as the womb condensed itself 
more and more, and at last became pretty well recovered. 

This lady, upon recovering in some degree her health, went on a 
journey to the western states, and came back in good health. Some 
time after her return to Philadelphia, she was found to be pregnant, 
and was attended in her accouchement by Dr. Levis,. who delivered 
her of a healthy child. 

I have received a letter from Dr. Hatch, of Kent, in the State of 
Connecticut, which I here present to the reader. 

Dear Sir: — I respectfully submit to you the full history of a case, 
to which, you may recollect, allusion was made while passing a social 



553 

evening at your house during the session of the American Medical 
Association at Philadelphia, in May, 1847. 

On the 22d of August, 1845, Mrs. H., aged twenty-four years, was 
delivered of her first child. The labor was easy and natural: the 
placenta was expelled, without interference, about twenty minutes 
after; the flow was rather copious, yet not enough to cause any alarm- 
ing depression of the system. Fourteen or fifteen hours after, she 
was seized with pains (said her nurse), of unusual severity for after- 
pains, which continued with great frequency for from two to three 
hours, when they suddenly ceased, and Dr. Beardsley, an elderly 
gentleman of the profession living near, w T as called in, being myself 
at the moment out of the village, who, on my arrival shortly after, 
gave the following account : — " The patient was very much exhausted, 
surface cold, pale, and covered w r ith a profuse clammy sweat; con- 
stant tendency to faintness, and with a pulse so small and frequent as 
to render it difficult to count it. I gave diffusible stimulants, and 
employed, thoroughly, warm stimulating spirituous embrocations to 
the skin. Slight reaction coming on, I perceived within the vagina 
a tumor which protruded from the vulva, of a size one-third larger 
than a goose-egg, having an uneven surface consisting of little emi- 
nences at irregular distances from each other, which I judged to be the 
inverted uterus." 

We made an effort to replace the organ. Carrying my hand within 
the vagina, after inspecting the presenting surface, which I found to 
be, as I suppose, the womb, the thumb was applied to the fundus, 
which I w T as able to carry within the body of the organ at least two 
inches; when at this point, it met with unconquerable resistance, and 
produced much uneasiness to our patient. Our efforts at its reduction 
w T ere suspended, and an opportunity allowed for rest. The fore part 
of the following day Mrs. H. was comfortable. In the afternoon she 
became restless: in part doubtless from retained urine. On being 
raised up, she experienced increased sensation of pressing down, when 
it was ascertained that the tumor had again, in part, protruded. Being 
returned to a recumbent posture, the tumor was pressed from its bear- 
ing on the urethra, and the bladder was- relieved. A messenger was 
dispatched to New Haven, a distance of fifty miles, who arrived with 
Professor Beers, of the medical institution of Yale College, about the 
commencement of the fifth day of the case. 

I continue the story by copying from a letter this day received from 
Dr. Beers, who, in order to make a connected history of the case, 
transcribes a portion of a letter I addressed him, which transcript is 



554 INVERSION. — DR. 

given in substance above. Prof. Beers writes as follows: " The fore- 
going relation of this case was communicated by Dr. Hatch in a letter 
to me, eight months after its occurring, coming down to the time when 
my own observation commenced, which was on the fifth day from her 
accouchement. The tumor was found as above described; its size 
w T as that of a healthy, well-contracted uterus ; a week after delivery 
it manifested the elastic, firm feel of that organ — had feeling, but not 
highly sensitive. The patient bore continued and forcible pressure 
with little complaint; the abdomen was soft, not full; the uterus could 
be felt when firmly pressed up above the pubis, and subsided into the 
vagina when the pressure was removed. There was no doubt of its 
being a case of complete inversion of the uterus. 

" The comfortable state of the patient — her anxiety, with that of 
her friends, and her fortitude to bear any operation which was deemed 
prudent — induced the council, with scarcely any expectation of suc- 
cess, to attempt its restoration by mechanical force, carried as far as 
it should be found could be borne with safety. For this purpose, two 
instruments were procured with smooth, turned heads, like that of a 
common walking cane, the larger about two inches in diameter, and 
the smaller of half that size. The smaller was most used, as it was 
found better to retain its place on the tumor; the head of the staff 
was applied to the centre of the tumor, which was the fundus of the 
uterus; moderate, continued, and at length firm pressure was made 
in the direction of the axis of the pelvis. The head of the instrument 
indented perhaps an inch or more into the tumor, and the whole pressed 
so high that it might be felt above, or even with the pubis. The in- 
verted fundus and body of the uterus were pressed into its more soft 
and yielding neck, so that it could be felt as it is in parturition, pro- 
jecting around the more solid part of the tumor, giving flattering hope 
of ultimate success. This was continued four or five hours. After 
its removal, and several hours' rest, it was found that no benefit was 
derived from the operation, the parts having returned to the same state 
as before the attempt." 

I am enabled to add that Dr. St. John, of New Melford, was of the 
council in attendance upon Mrs. H. ; a gentleman whose accuracy 
in diagnosis commands of his professional brethren about him very 
high respect, and who authorizes the statements here offered. 

I have introduced the accounts of the gentlemen who saw this in- 
teresting case, that, in the mouth of two or three witnesses, its true 
nature may be established. I follow with its subsequent history, which 
may be considered to lend an item of some interest in support of the 



555 

position you maintain, in a recently published work, regarding the 
possible spontaneous reposition of the inverted uterus. 

The convalescence of Mrs. H. was slow, but in four or five weeks 
she was able to walk across her room, and gained strength steadily 
thereafter; was soon able to ride out ; but when in an erect position, 
suffered a sense of dragging weight in the pelvic region, and often 
spoke of the tumor as not having sensibly diminished in size, and was 
continuing to occupy a low position. Between nine and ten months 
had passed in this way, since her misfortune, when I was informed 
that the tumor had then lately so changed its location, " that she knew 
not what had become of it." In the month of February, 1847, she 
had a profuse menstrual flow, the first considerable evacuation of the 
kind she had experienced since in this state; and in March a second 
eruption still more abundant occurred, from which she was somewhat 
reduced. Nothing of the kind recurred, and she passed the following 
spring and summer seasons in good health. Early in the winter, I 
think in December last, I was applied to for my opinion as to the 
question of her pregnancy, and was led to concur with the patient 
herself, in the belief that such was probably her condition. No ex- 
amination per vaginam was had. On the 23d of May last, at four 
o'clock P. M., Mrs. H. was attacked with a hard chill, and a sponta- 
neous rupture of the membranes immediately ensued. Slight pains 
came on and recurred at very short intervals till six o'clock, when 
she was delivered of a boy, whose weight was nine pounds and six 
ounces. Very slight pains followed at intervals of from twenty minutes 
to two hours. There being no considerable hemorrhage, I patiently, 
but watchfully, w T aited, while as a precaution, perhaps unnecessary, 
I introduced the staff spoken of by Prof. B. by the side of the cord, 
within the uterus, till it rested gently on the fundus, nor till six o'clock 
next morning, did the placenta descend — wdien it lodged low in the 
vagina, and was removed. The patient and her child are now well. 
Yours, w T ith high regard, 

JOHNSON C. HATCH. 

Kext, Connecticut, July 1st, 184 S. 

I have already announced, in a note to M. Colombat's Diseases of 
Females, and in my Letters on Females and their Diseases, p. 239, the 
opinion that there are instances of inversio uteri, in which, by means 
of some power, the processes of which are at present not known or 
understood, the womb reposits itself. The two cases of such occur- 
rence that I related in my "Letters," and the case now given upon 



556 INVERSION. MR. CROSSE. 

the authority of Drs. Hatch, Beardsley, St. John, and Beers, appear 
to me to be quite sufficient to establish the facts. 

It is true that Mr. Crosse, of Norwich, in England, in his valuable 
work, entitled An Essay , Literary and Practical, on Inversio TJteri, at 
p. 177, does not agree with me in the opinion that the first two cases 
here recited are really cases of spontaneous reposition. " It is easier," 
says he, " to cast a doubt over the reality of these spontaneous reco- 
veries, than to remove the obscurity that pervades the subject gene- 
rally." Dr. C. also hints that I and my friends may have mistaken 
a polypus for an inversio uteri. Mr. Crosse's words (note), p. 177, 2d 
part, are as follows : 

" First Case. — The disease dated from her delivery, two years 
before, and had existed for that length of time, when Dr. Meigs was 
consulted. He took the greatest pains to discriminate, and remained 
under the absolute conviction of its being inversion of the womb ; 
several others concurred in the same opinion. Fruitless attempts were 
made to reduce the part. Four years afterwards she became preg- 
nant. Second Case. — Nearly five weeks elapsed after delivery before 
the patient was examined and the vaginal tumor investigated by the 
speculum, and also by the hand introduced into the vagina, till two 
fingers passed within the cervix uteri and reached the limit of the cul- 
de-sac, enabling the investigator to convince himself that the tumor 
within the vagina was i the inverted womb and nothing else.' After 
a temporary absence, this patient returned, became pregnant, and 
gave birth to a child. Hence Dr. Meigs concludes, that the inverted 
womb 'may reposit itself in some rare instances.' (Colombat de 
VIsere, Dis. of Women, translated by C. D. Meigs, pp. 182-4.) The 
deficient account of the method of diagnosis in the first case is, in 
some degree, supplied in the second; but there is still an absence of 
that minute detail of proceedings which, in the present day, is alone 
calculated to convince the skeptical reader. It may be asked, if we 
suppose in either case there was polypus, and not uterine inversion, 
c What became of the polypus?' Perhaps it may be answered, that 
it is more easy for a polypus to be separated and thrown off than for 
chronic inversion of the uterus to reposit itself spontaneously. W hilst 
the question remains undecided, and further evidence is needed, we 
have only to take care that the right rule of practice prevails. Vel- 
peau, one of our best authorities on chronic inversion, remarks : — 
'Des faits de ce genre ne doivent etre considerees que comme d'heu- 
reuse exceptions ; il n'est pas aucunpraticien sense qui oserait comp- 
ter sur depareilsresultats.' (Lemons Orales de Clin. Chir., ii. 427.)" 



INVERSION. — MR. CROSSE. 557 

It ought not, perhaps, to expose me to a charge of excessive con- 
fidence in my own perceptions and judgment, if I should say that 
in both the cases I took the greatest pains to make the discrimination 
— that I have treated many cases of uterine polypus, and that I have 
practised as an accoucheur, and been largely engaged in treating 
the diseases of females, for many years past. Under such circum- 
stances, and supported by the coinciding opinions of Drs. Moehring, 
Hodge, and Warrington, I aver that no mistake was made. I am 
now strongly confirmed in my belief by Dr. Hatch's case, which seems 
to me to preclude all cavil as to the question. 

Mr. Crosse cites Velpeau's words, who says that "facts of this kind 
may be perhaps regarded as the happy exceptions to a general rule ; 
but there is no intelligent practitioner who would dare to rely upon 
such results;" and Mr. C. adds, "If we subtract all errors and admit 
only the well-authenticated cases, it may still be remarked that spon- 
taneous replacement is too rare an occurrence to have any influence 
upon the correct rule of practice, viz., the effectuating by art the re- 
duction of partial inversion of the womb in all its different degrees." 

These remarks are just and true. Yet as cases do occur in which, 
from the lateness of the detection of them, or from other causes, the 
reduction is found to be impossible, it is a most important and con- 
solatory reflection, that there remains the hope of a spontaneous re- 
placement, while we are guarded against the danger of making a 
discreditable prognosis. There is certainly very little hope for a wo- 
man affected with irreducible inversion of the womb, except this very 
case of exceptional hope, which I have endeavored to establish, and 
which, I think, ought not to be gainsaid after the testimony in its favor 
now given. Moreover, there is very little risk that any person worthy 
the name of Physician, would ever desist from every reasonable at- 
tempt at chirurgical reduction, on account of any degree of confidence 
he might indulge in a possible spontaneous replacement of the inverted 
womb. 



558 PUERPERAL FEVER. 



CHAPTER XIX 



PUERPERAL FEVER. 



Puerperal fever, child-bed fever, puerperal peritonitis, peritoneal 
fever, and other names, are terms applied to a dangerous form of in- 
flammation to which lying-in women are exposed, and which pro- 
bably occasions a far greater amount of fatal results than any other 
disorder met with in the whole range of obstetric practice. In 
former times very imperfect views were taken concerning the nature 
of these violent affections. Seeing that they were accompanied with 
an early sinking and rapid extinction of the vital powers, recourse 
was too soon had to supposed means of sustaining the strength of the 
patient. Hence, wine, bark, opium and heating methods in general 
were resorted to, but without other effect than to increase the inflam- 
matory congestions which were the real causes of the apparent de- 
bility, and precipitate a fatal result which might, in numerous in- 
stances, have been averted by measures founded on juster views of 
the pathology of the case. There has long been a very great differ- 
ence of opinion among medical men in regard to the proper mode of 
treating this disorder, and I am unable to repress a feeling of deep 
regret on account of the continuance of that difference at a period 
when the light shed upon the subject by numerous and careful exami- 
nations of the bodies of victims, has left no doubt upon the mind 
as to the real and essential nature of the disease, now universally ad- 
mitted to be inflammation of the womb, of its appendages, or of the 
peritoneum — and sometimes of all of them together. 

There is good reason for believing, however, that sounder views of 
the nature and treatment of child-bed fever are extending rapidly in 
the republic of medical letters, and the day, it is to be hoped, is not 
far distant, when such works as those of Alexander Gordon, of Hey, 
and of Robert Lee, will be able to establish a firm conviction of the 
reasonableness and truth of the doctrines and practice they severally 
set forth; and that a very great reform may be soon effected in the 



PUERPERAL FEVER. 559 

treatment of these cases, to the advantage of the public and to the 
greater honor of the medical profession, whose highest glory it is to 
reduce the amount of the per centage of fatalities in the various forms 
of disease entrusted to medical care. 

Considering the state of the patient's constitution immediately after 
the fatigue of gestation, the excitement and efforts of labor, the altered 
and diminished tension of all the parts contained within the abdomen 
and pelvis after parturition, we ought not to feel surprised at the fre- 
quent occurrence of inflammation in those parts. 

The womb itself has been suddenly reduced from the gravid to the 
non-gravid state ; it has thrown off the large mass of the placenta, 
leaving the surface to which it had been attached bleeding, and re- 
quiring a sort of healing process. Many orifices filled with plugs of 
coagulum, some entering a considerable distance into the veins, are 
found gaping upon its inner aspect. These orifices are the openings 
of tubes communicating with the veins of the womb; they are lite- 
rally open veins lined with the membrana vasorum commune, the En- 
dangium. It is probable that these orifices never close after any 
labor, except by the intervention of an adhesive inflammation. The 
muscular tissue is about to be reduced so much as to be no longer 
distinguishable by the anatomist's eye; large veins and sinuses are 
to be crushed and rendered invisible ; absorbing vessels, nerves and 
membranes, all are about to be put upon the reduced establishment, 
and this by a process of the most active absorption, for the womb is 
to be reduced from its post partum weight of a pound and a half to 
its non-gravid weight of two ounces and a half, requiring an immense 
activity of its absorbent vessels, and probably a vast operation of 
exosmose. These circumstances, I say, should prevent any surprise, 
if, in the midst of so great a revolution of the reproductive tissues, 
violent disorders should make their appearance. 

There is, in fact, greater reason for surprise when we find a child- 
birth not followed by inflammation, than when we meet with the most 
violent and destructive cases of that affection. 

The peritoneum, a serous membrane known for ages as one of the 
tissues most ready to take on inflammation, undergoes, in labor and 
during the lying-in, changes of the greatest importance. Its great 
extent may be known by computing the superficial contents of that 
portion of the serous membrane which invests the alimentary canal. 
This canal is about forty feet in length, and its outer coat is com- 
posed of peritoneum. If cut up from end to end by the enterotome, 
it would be at least four inches wide and forty feet long, affording a 



560 PUERPERAL FEVER. 

superficies of more than thirteen feet, to which should be added the 
superficial contents of the remainder of the membrane, where it in- 
vests the liver, the epiploon, the mesentery and mesocolon, besides 
the ligamenta lata, and all the other parts which derive from it their 
serous covering. This vast surface inflames rapidly and totally, and 
passes through the stage of inflammation with extraordinary speed. 
It cannot happen that it shall ever be extensively inflamed without a 
coincident exhibition of the greatest disorder in the functions of the 
nervous organs directly implicated in its structure, or possessing with 
it physiological relations that could not be safely disturbed. The 
peritoneum is the investiture of the abdominal organs ; the peritoneal 
coat of the stomach is as truly a part of the organ as its muscular or 
mucous coat; the same is true as to the peritoneum that invests the 
liver, that of the spleen, and the same truth is of the utmost import 
when it is stated with regard to the peritoneal coat of the whole ali- 
mentary apparatus. It is clear that extensive or universal inflamma- 
tion of the peritoneal membrane is inflammation of all or many of 
the organs contained within the cavity 01 the abdomen. A great 
puerperal peritonitis, therefore, may be properly regarded as a com- 
plex inflammation of a vast number of organs indispensable to exist- 
ence ; why should we be astonished, then, to see the power of the 
nervous mass sink under the invasion of causes of destruction so great 
and so pervading. 

Seeing that the superficies of the peritoneum is equal probably to 
thirteen or fourteen feet, we should have abundant reason to dread so 
extensive an inflammation, from the constitutional irritation which it 
alone would produce; but when, in addition to that consideration, we 
take into view the great effusions which may ensue, the suppurations, 
the interruption of the intestinal functions, the depravation of the 
actions of the liver, &o., which are occasioned by it, we have still 
greater reason to deprecate its attack, and to seek for the justest 
views of its nature, and of the remedies most appropriate for its cure. 

Peritoneal inflammation occurs more frequently in women in child- 
bed than in any other class of persons. It generally follows labor 
within from two to four days ; but it may occur either earlier or later; 
sometimes making its attack even before labor begins, and being de- 
ferred in other cases until the third week of the confinement, or even 
later. 

The subject is predisposed to it, probably from various causes, 
among which are the severe pressure which occurs during the expul- 
sive efforts for delivery; the extreme distension which the membrane 



PUERPERAL FEVER. 561 

has suffered in the last weeks of gestation; the violent excitation of 
the womb itself by labor pains ; the complete relaxation of the mem- 
brane and its adjacent tissues, following the birth of the child, and, 
lastly, the modifications as to the state of the Endangium of the uterus, 
particularly that portion of it which remains open on the inner sur- 
face, giving issue to the lochial discharge. 

The pressure produced by the bearing down of the woman in labor 
is often so great and so long continued, that an effect analogous to 
contusion cannot fail, in many instances, of taking place ; since the 
whole power of the abdominal muscles is expended in propelling 
the uterine fundus towards the os uteri. Such contusions of con- 
tiguous portions of the peritoneum would be readily followed by in- 
flammation, and the more readily in proportion as these efforts might 
have been greater or longer continued, and, in fact, we do find that 
bad labors are more apt to be followed by peritoneal fevers than easy 
or good ones. 

The peritoneal coat of the womb is greatly expanded or stretched 
in the last stages of pregnancy. The broad ligaments and the liga- 
menta rotunda, are drawn up on the sides of the uterus to a consi- 
derable height, w r hile the portion of the membrane that lines the front 
and sides of the belly is also put greatly on the stretch. This ante- 
cedent tension could not but increase its natural proneness to take on 
inflammatory action, if exciting causes should be applied to the peri- 
toneum, when after delivery so great a relaxation has taken place. 

The womb itself is left after labor with so great a disposition to 
inflame, that very slight occasional causes suffice to set that disorder 
on foot in the structure of the womb itself, which may serve as the 
radiating point for a peritonitis that shall involve the whole extent of 
the serous tissues of the belly. It is very common in the post-mortem 
examination of puerperal fever cases, to find the results of inflamma- 
tion not only on the serous coat of the uterus, but also in its proper 
structure, as well as in that of the ovaries. These results are evinced 
in the effused pus found in the substance of those organs, and in their 
veins. There are many examples to be met with of fatal puerperal dis- 
ease in which the peritoneum alone discloses the evidences of grave 
lesion; there are also very numerous instances of like fatality in which 
the uterus itself appears to be the only organ affected in these uterine 
cases ; it is probable that the ipsissimus morbus is Endangitis, com- 
monly called metro-phlebitis. I advise the reader to consult upon 
this head, the volume on puerperal fever, published here by Haswell 
& Barrington, in which he will find the precious writings of Gordon, 
36 



562 PUERPERAL FEVER. 

Hey, Armstrong and Lee. That work alone should suffice thoroughly 
to indoctriuate him in regard to the nature, signs, causes and cure of 
child-bed fever. 

The relaxation of the peritoneal membrane that follows delivery 
and the reduction of the womb to a small size, is, beyond doubt, one 
of the most fruitful sources of inflammation of the membrane. The 
sanguine determinations are also greatly affected by the relaxation of 
the muscles and integuments of the belly, consequent upon the com- 
plete contraction of the womb. It will not be denied that the blood that 
escapes from the aorta by the cceliac and the mesenteries, as well as 
that which passes along the spermatic and uterine arteries, will meet 
less resistance to its flow where the tegumentary and muscular tissues 
of the abdomen are quite flaccid and devoid of tone, as after child- 
birth, than where they are in a state of great tension, as before labor 
commences; but if the blood of the chylopoietic organs reaches their 
capillary vessels with less resistance or greater facility, then those 
organs will be more liable to sanguine affluxions, engorgements and 
irritation, on account of this very weakness and relaxation. 

A similar liability exists for patients who have been tapped for 
ascites. Such patients are extremely apt to be seized with peritonitis, 
which, however it may be in a measure considered as a consequence 
of the wound made by the trocar, is, nevertheless, more apt to ensue 
in such as are not carefully bandaged after the tapping, than in those 
who procure a proper degree of compression by a bandage which 
serves as a substitute for the tone, or rather resistance of the muscles 
and integuments, which is almost wholly abolished, at least for some 
hours or days, by the drawing off of the water from the peritoneal sac, 
as it also is after delivery. 

Let us suppose the case of a woman who has just given birth to a 
child of eight or nine pounds weight. She has had perhaps sixteen 
ounces of water in the womb, and an after-birth weighing a pound. 
Previously to the birth of the child, the greatest or vertical circumfer- 
ence of the womb was about thirty-five inches, and its horizontal cir- 
cumference twenty-five inches; after delivery it becomes so reduced 
as to jut but little above the plane of the superior strait, whereas, 
before the accouchement, it rose as high as the xyphoid cartilage. The 
change in the state of every part of the sanguiferous apparatus within 
the belly after delivery, is very great indeed, and the forces which 
impel the blood into those vessels being equal to, if not greater than they 
were before the resistance was lessened by the delivery, it follows that 



PUERPERAL FEVER. 563 

the stroke of the ventricle upon the aortic column must necessarily pro- 
pel a large proportion of blood into the less resisting tissues or vessels. 

Every blood-vessel, whether arterial or capillary, may justly be re- 
garded as a hollow cylinder, containing within its calibre a column 
or cylinder of incompressible blood, which, by a slight effort of the 
imagination, may be conceived of as reaching backwards from the 
capillary or arterial tube itself to the origin of the aorta. Suppose 
the capillary to be dilated, distended, or engorged with blood, as it 
confessedly is when in a state of inflammation. Suppose also the 
ventricle to contract with febrile force in such a way as to propel its 
contents, amounting to one ounce of blood, suddenly into the aorta; 
of course that portion of the blood amounting to one ounce that was 
in the aorta and nearest its valves, was moved downwards to make 
place for the following wave, the ounce next to it in advance was 
moved at the same time, and by the same blow, and so on to the last 
ramification of the artery, and far onAvards into the capillary system 
of vessels. It is easy to see the globules in a transparent membrane 
placed under a microscope, move forwards per saltum with each suc- 
cessive systole of the heart. Let us now suppose a portion of the 
peritoneum, say two inches square, to become inflamed from any cause, 
is it not easy to conceive that every successive blow upon the arte- 
rial column struck by the ventricle, will drive hundreds of columns 
along the capillaries, like so many wedges into the contiguous capil- 
laries, and that the inflammation will spread, as fire in dry grass, in 
every direction, and with every succeeding blow, until the whole extent 
is involved in the desolation? Such and so great is the rapidity with 
which this serous membrane inflames, that many cases are recorded 
in which death was brought about within thirty hours after the attack, 
with great deposits of effused lymph or sero-purulent effusions into 
the cavity of the peritoneum. 

Puerperal women are not the only subjects and victims of peritonitis, 
for non-gravid women, and the male sex of every age, are liable to 
the disease, which, however, in them, proceeds with far less haste to 
its destructive termination. 

Taking this view of the tendency which the relaxation, or want of 
tone or support, occasioned by delivery, gives to attacks of peritonitis, 
I find it not surprising that those women who get up too soon, or sit up 
too long, should suffer more readily than those who preserve a hori- 
zontal posture for several days after childbirth. A woman who gets 
up very soon, is much exposed to the dangers of flooding, from the 
sudden engorgement of the uterine vessels occasioned by a vertical 



564 PUERPERAL FEVER. 

position. The hemorrhage that often comes on in consequence of 
this imprudence, is an effort of nature to relieve the engorgement of 
the abdominal and uterine blood-vessels, produced by a too early- 
getting up ; but, where this relief is not procured by evacuation of 
the engorged vessels, inflammatory excitement may supervene, espe- 
cially if the centripetal determination of the blood is augmented or 
reinforced by the occurrence of chills, to which the woman is more 
obnoxious out of bed than in it. Not a few of the cases of peritoneal 
inflammation that have come under my notice, were clearly attributa- 
ble to the imprudence of the patient in getting too soon out of bed. 
Such an act of imprudence ought not to be permitted. 

Vascular excitement, from whatever cause produced, may become 
fixed upon the serous membrane of the belly as an inflammation 
possessing all the dangerous characteristics of child-bed fever; a for- 
tiori, such inflammations are more likely to attack the tissue of the 
uterus itself; hence, in seasons of an epidemic prevalence of child- 
bed fever, the physician, who ought to be truly the guardian of his 
patient, should feel bound, more than in ordinary times, to protect her 
from the dangers by which she is surrounded by the most careful and 
precise directions and orders relative to her management in the 
lying-in. A common milk fever, therefore, ought not to be permitted to 
become very violent, lest it might produce the result just mentioned. 
It should be fully and promptly reduced by venesection and cooling 
purgatives, and above all by a strict observance of the horizontal 
position. Fever of any kind coming on soon after delivery includes 
at least a risk of an attack of peritonitis. 

Improper diet, and whatever might occasion indigestion, should be 
carefully avoided, lest the intestinal irritation, if severe, should be- 
come peritonitis in one predisposed that way. I speak upon this 
point from my own observation, having recently seen two women, 
both of whom had peritonitis from indigestion occasioned by the use 
of a kind of food which is very generally given to lying-in women. 
Great care should be taken to avoid all kinds of indigestible food. 

Costiveness, a very common complaint towards the close of preg- 
nancy, should be obviated by the administration of gentle aperients 
or enemata. An overloaded state of the bowels might very reason- 
ably be supposed sufficient to excite irritation in the abdomen, which, 
in individuals predisposed to peritoneal inflammation, would become 
fixed at last upon the serous surface. 

Suppression of urine, an occurrence frequently met with in obstetric 
practice, should be carefully watched, since an undue degree of dis- 



PUERPERAL FEVER. 565 

tention of the bladder can scarcely take place without endangering 
the life of the lying-in woman, from the tendency which accompanies 
it to excite the first movements of peritoneal or metritic fever. It 
should always be regarded as a part of the duty of the medical attend- 
ant, to inquire into the state of the bladder after the labour is over; 
and it is far better to resort at once to the catheter for relief, where 
there is any reason to suspect an accumulation of water, than to con- 
fide in the various diuretic drinks, or even to the enema, which, 
although less disagreeable, are far less certain remedies than the 
catheter. It is scarcely ever proper to defer a recommendation of the 
use of the catheter, where many hours have elapsed after delivery 
without a urinary evacuation; even if the patient complains of no 
pain. I have observed, in some instances, a very great collection to 
be unattended with decided pain. 

It is highly important to pay strict attention to the after-pains of 
w T hich puerperal woman so commonly complain. If they go off per- 
fectly — leaving intervals between the contractions; and especially 
if, in those intervals, there is no soreness of the hypogastric and iliac 
regions upon pressure made thereon with the hand ; or if the woman 
can cough without producing pain in the hypogaster ; or if suddenly 
drawing up the thighs or rotating the lower extremities produces no 
pain in the lower belly, they are of little consequence ; but w T hen they 
do not leave the patient w 7 ith good intervals of freedom from pain, 
they should be held suspected, and be quelled by anodyne doses, by 
enemata, and even by the use of the lancet. Obstinate al'ter-pains, par- 
ticularly those which continue for several days, not very rarely serve 
as the masks of a peritonitis, which is the more dangerous from having, 
by its insidious approach and attack, beguiled the unwary practitioner, 
until his means of resistance, w 7 hich at the beginning might have 
proved completely adequate, have, by procrastination, lost all efficacy. 
In urging the attention of the student to this point, I by no means 
wish to be understood as asserting that it is always easy to discriminate 
between after-pains and the early stages of a peritoneal fever — on the 
contrary, it is on account of the difficulty of making such a diagnosis, 
that it becomes important to attend sedulously to the symptoms. 
Those peritoneal fevers, and they are not few, which are connected 
with an inflammation of the uterine sinuses, are the most dangerous; 
and I have no doubt that some of the very distressing after-pains 
w r hich we meet with in practice, but which w T e subdue, are occasioned 
by a high degree of inflammatory irritation of the uterine texture, 
whose course being happily checked leaves us without any fatal or 



566 PUERPERAL FEVER. 

post-mortem evidences of its existence. I am free to say, that I have 
often been very much embarrassed to decide whether my suffering 
patient was affected with mere spasmodic contractions of the womb, 
or with rheumatismus uteri, or whether she laboured, in addition to 
such spasm, under an inflammation of that organ. I have many times 
abstracted blood freely for the relief of the symptoms, and, obtaining 
complete relief, have remained still uncertain whether my remedy 
had put a stop to spasm merely, or whether it had overcome an inci- 
pient inflammatory excitement of the uterus and ovaria, by which the 
patient was exposed to the greatest dangers of fatal peritoneal fever. 
I beg leave to repeat, that after-pains ought to be carefully w T atched, 
and when accompanied with an excited circulation and tenderness 
of the hypogastric region, should be met by free depletion as the chief 
of remedies. There are other remedial measures that need not be 
again spoken of here. 

There is, unquestionably, an epidemic influence or atmospheric 
constitution which sometimes, in extensive districts of country, in 
villages, in towns and cities, and especially in crowded lying-in hos- 
pitals, determines by an unknown force the attack of child-bed fever, 
and so modifies the pathogenic conditions as to hurry numerous vic- 
tims to the grave, and this notwithstanding the employment of the 
most reasonable methods of cure. From the coincident prevalence 
of child-bed fever and erysipelas, it has been, by some, supposed that 
there is a unity of causes for the two diseases. Be it so: the cause 
remains not the less unknown, nor can I bring myself to the convic- 
tion that that epidemic cause can in any degree modify the science 
and the art of the practitioner who is charged with the cure. If me- 
tro-phlebitis and metro-peritonitis, be truly inflammation, they are so 
under every possible modification of the atmospheric or epidemic 
constitution; if that epidemic constitution is inflammatory or sthenic, 
the indication for the treatment leads to the employment of the anti- 
phlogistic resources. Happily for us, under such a taxic constitution 
of pathogeny, our therapeutical resources, of an antiphlogistic kind, 
prove to be the obedient servants of our will; under ataxic forms of 
the epidemic pathogeny, our therapeia can never change the truth into 
a lie, teaching us that these same inflammations are to be cured by a 
mode of treatment contrary to the truth, both of physiology and pa- 
thology. Experience gives us no records of cheering success in the 
treatment of ataxic epidemics of child-bed fever, by means merely of 
alteratives, and stimulants, and alexipharmics, and tonical articles 
from the materia medica. If we cannot cure by venesection we shall 
in vain attempt to cure. 



PUERPERAL FEVER. 567 

There appears to me to be a growing disposition on the part of the 
profession to look to contagion as one of the causes of what is uni- 
versally admitted to be an epidemic disease, and the facts that have 
been set forth in confirmation of this idea are sufficient to startle the 
most imperturbable mind. For my own part, however, notwithstanding 
I have given to these statements all the attention which the authors 
of them demand at my hands, I remain hitherto unconvinced of the 
powers of contagion to extend this fatal disease. A great experience 
has not enabled me to perceive that I have been the means of dis- 
seminating this malady among lying-in women, to whom I had given 
professional aid while attending upon dangerous and fatal attacks of 
the malady, or after making or witnessing autopsic examinations of 
the bodies of the dead. The chain of causation is too fine to be dis- 
cerned, and as I w T holly reject the doctrine of contagion in yellow- 
fever, in Asiatic cholera, in measles, and in scarlatina, I remain 
equally recusant as to the contagion of puerperal peritonitis, and me- 
tro- and crural phlebitis. 

Puerperal fever, generally, is ushered in with a chilly fit, more or 
less considerable, and of various duration, but ordinarily not very long ; 
the pain which accompanies it commences in the hypogastric or one 
of the iliac regions, and increases and extends its limits as the fever 
augments. The fever is occasionally very high, while the pain is not 
very intense, and in the epidemic cases of the malady, some women 
are met with who do not even complain of pain at all, notwithstanding 
the most active inflammatory changes are going on in the abdomen, 
as disclosed by post-mortem examinations. 

The vascular system, when moved by peritoneal inflammation, 
reacts with the greatest promptitude ; the pulse acquires a frequency of 
rarely less than 120, and commonly 140, strokes per minute. In the 
early stages of this vascular reaction, in sporadic cases, the artery is 
full, strong, and possessing the characters of the synochus fortis pulse : 
but this high grade of energy is soon passed; the pulse acquires 
greater frequency, with diminished hardness and volume. If the in- 
flammation, like a rushing fire, seizes on the whole serous membrane, 
or attacks the mass of the uterus, the constitutional irritation which 
is produced by it rapidly exhausts the vital powers, and the patient 
sinks very much in the way that those surgical patients perish who 
have suffered extensive laceration or fatal injuries of some great ar- 
ticulation. All remedies are useless when the whole nervous and 
vascular systems have suffered a shock sufficient to overthrow their 
functional power, and the patient sinks rapidly, in despite of the cor- 



568 PUERPERAL FEVER. 

dials, the opiates, the counter-irritants and other appliances which 
are, in a sort of desperation, resorted to by the medical attendant. 
A child-bed fever should be cured very soon, or it will scarcely be 
cured at all ; and why should we expect to cure a peritonitis which 
we have reason to suppose connected with an inflammation of the 
whole serous membrane? If a small part of that membrane only be 
affected^ as is the case in the commencement, we may hopefully en- 
deavor to effect a resolution of the inflammation by bleeding, &c, but 
when it has had time to be wholly involved in inflammation, I think 
any experienced practitioner will agree with me in expecting the 
inflammation to result not in resolution, but in effusion; which effusion 
ends in death very commonly. 

Such is the rapidity with which the peritoneum becomes universally 
involved in inflammation, that not a few persons have, in their writings, 
brought into some discredit the use of the lancet as a remedy, their 
own judgments having been staggered by the vain employment of the 
remedy in stages wherein the loss of blood could not do good, and 
seemed only to precipitate the fatal result. A woman, for example, 
may be attacked with the disease after the physician has seen her in 
the evening; the nurse, who supposes that all pain in the abdomen is 
after-pain, and all fever, milk fever, does not become alarmed, and 
when the physician arrives, he finds the patient already far advanced 
in, or at least on the point of, those effusions into the peritoneal sac, 
which, w 7 hile they put an end to the pain, also seal the fate of the 
unhappy mother. Such events have occurred under my own practice. 

I would earnestly endeavor to impress upon the mind of the student 
of medicine the vital importance of great promptitude in his attention 
to the earliest signs of this dreadful malady, especially during the 
epidemic prevalence of it. I would convince him that the principal 
feature in the disease called child-bed fever is peritonitis or metritis, or 
metro-phlebitis — that the inflammation is so acute, and the tissue in 
which it is seated so inflammatory, that the malady is capable of 
hurrying through its curable stages more rapidly than even the re- 
doubtable croup, and what is of still greater moment, that it is in the 
incipient stages nearly as curable as croup, and that the remedy, or I 
might say the cure, consists in the bold and judicious em- 
ployment of venesection. Let me ask, what can be the value 
of any remedy short of venesection, in a malady like this — which pre- 
sents a case of pure inflammation — occupying, or making haste to oc- 
cupy, not a few square inches, but many square feet of a membrane 
that serves as the investment of the most important organs? In what 



PUERPERAL FEVER. 569 

light, save as mere juvantia, can any reasonable man regard the few 
grains of calomel and opium, or ipecacuanha, or the few drops of spirits 
of turpentine, which are by some persons given as remedies for such 
wide-extended mischief? Nothing but abstractions of blood can have 
an immediate and potent influence on the circulation, and reduce the 
momentum of the blood to such a degree of moderation, as may con- 
sist with a resolution of the inflammation. Nothing short of these 
venesections can diminish the force of the blows which the irritated, 
I might say the infuriated, ventricle strikes upon the columns of blood 
which it is driving like so many riving wedges into the tissues, to 
disorganize, to tear them to pieces, and overwhelm them with the 
torrent of circulation that it urges upon them, while their power to 
resist succumbs to every successive blow. Every systole of the heart 
is an effort for the development of the tissues in which the torrent of 
the circulation last arrives. The pathological modifications brought 
about by the hyperneuric and hyperaemic modality of the inflamed 
points are always exaggerated forms of development. The inflam- 
matory deposits, effusions, extravasations, new tissues and heterologue 
materials made manifest in a local inflammation, are specimens of 
teratology; they are all monstrosities. The duty of the physician is 
to prevent or lessen the preternatural operation of this development 
force. Peritonitis always has one or the other of these two termina- 
tions — resolution or effusion ; with the former the patient recovers, 
with the latter she dies. Dr. Gordon tells us, that it is not merely 
bleeding the patient that will save her. She must be bled copiously 
— so copiously as to give to the disease a definitive check. He tells 
us that where the woman is bled timidly, no available impression is 
made, that the disease advances and soon becomes indomitable. 
Twenty-five or thirty ounces drawn from the arm, early in the attack, 
rarely fail to make so powerful an impression on the disorder, that 
the juvantia, such as calomel, opium, &c, hardly fail to effect the 
remainder of the cure. 

All the experience I have had in regard to the course and treatment 
of this malady, leads me to concur fully with the instructions of Dr. 
Gordon on the subject, and it is alw r ays with regret that I reflect on 
the published opinions of Gooch and others, who appear to bring into 
distrust the best of all possible resources for the management of this 
violent disease. I scarcely can find words to express my admiration 
of Dr. Gordon's work upon Puerperal Fever. May I not venture to 
say that the subject cannot be well understood, until the physician or 
student has read that work, and read it carefully? Its publication was 



570 PUERPERAL FEVER. 

the turning point of the great therapeutical reformation going forwards 
in the treatment and knowledge of child-bed fever; and mankind owes 
an iinpayable debt to the author for the benefits he conferred on the 
race, by its clear, candid, and most important revelations of medical 
truths. To it we are, I suppose, really indebted for the luminous and 
satisfactory w T ork of Dr. Hey upon the same subject. And, doubtless, 
Dr. Robert Lee, whose principles and modes of treatment are so ex- 
cellent, would not dissent, if the palmam qui meruit fer at should be 
tendered to Gordon, who led the way at least, by his early publi- 
cation, to a philosophy of this disease, which Dr. Lee, in his " Re- 
searches," &c, has so successfully illustrated and explained. 

Dr. Gordon gives a table of the cases, with the names of the pa- 
tients, and the results of his practice, from December 1789, till Octo- 
ber 1792. They were seventy-seven in all, of whom there died 
twenty-eight patients, which is equal to one fatal case in every two 
and three-fourths of the cases submitted to his care. It should be 
remarked that when he had fully convinced himself of the propriety 
of the lancet, he was more successful, for his fatalities occurred among 
the early opportunities enjoyed for clinical observation and study. It 
was not until the fatal result of the expectant practice had astounded 
him, that he obtained permission to examine the body of one of the 
victims. The undeniable evidences therein discovered of raging 
inflammation induced him to adopt a bold antiphlogistic treatment. 
He had lost nineteen out of the first thirty-eight cases encountered in 
the epidemic. His thirty-eighth case afforded him the material for 
dissection; he afterwards attended thirty-nine cases of the malady, of 
which he lost ten, and saved twenty-nine. When he took away only 
ten or twelve ounces of blood, the patient died; "but when I 
had courage to take away twenty or twenty-four ounces 
at one bleeding, in the beginning'of the disease, she 
never failed to recover." 

I am almost ready to say, that the case of peritonitis which will not 
admit of the use of venesection, is hopeless — that all other medical 
measures are trivial, when compared with its prompt and salutary 
influences; and also, that I can with difficulty conceive of a case of 
the disease, in which the lancet would be inadmissible in every period 
of its origin and progress : there should be found some point of time 
in which it could be resorted to. While I profess in the strongest 
terms to confide in the lancet, as the first and chief remedy, I would 
not pretermit any mention of leeches, which, as a secondary and sub- 
servient prescription, will be found of the greatest utility in the manage- 
ment of the cases. They should be freely employed, by scattering 



PUERPERAL FEVER. 571 

them over the parts of the abdomen most affected with pain and sore- 
ness. Cataplasms and warm fomentations may be advantageously 
used after the removal of the leeches, and the bowels should be well 
evacuated by means of enemata, or by doses of calomel and castor 
oil, to be followed, after the operation, by doses of calomel and opium, 
or calomel and Dover's powder, w T ith w T arm mucilaginous drinks. 
These serve, after the evacuation of the bowels, to promote perspira- 
tion, which, when properly excited or produced, counteracts, in an 
eminently useful manner, the internal disorders of the circulation. 

In regard to the power of mercury, I believe that it is able, in large 
doses, to exercise upon the nervous mass an influence, the operation 
of which serves to diminish the plasticity of the blood. I know of no 
objection, therefore, why the Student should not, after the great, in- 
dispensable venesection, give full employment to the aplastic proper- 
ties of the mercurial preparations. By means of the judicious, bold 
administration of mercury as an adjuvant, of the prime measure, 
the venesection , patients may be rescued from a death which the 
venesection could not, perhaps, arrest. 

I feel very sure that the whole body of medical men are under the 
greatest obligations to Dr. Robert Collins of Dublin, late Master of 
the Lying-in Hospital of that city, for the work which he has recently 
put forth. That work is the result of a long and most attentive and 
recorded experience; and, taken as a whole, may be justly regarded 
as one of the really valuable contributions to medical science of modern 
times. While, however, I am thus ready to profess very cordial admi- 
ration of the work, I cannot suppress a feeling of regret on account 
of what he has given us on the subject of puerperal fever. 

During the seven years in which Dr. Collins was master of the hos- 
pital, there w T ere delivered in the institution sixteen thousand four 
hundred and fourteen women, of whom one hundred and sixty-four 
died; of this number, fifty-six died with puerperal fever. The whole 
number of persons who were attacked w T ith the disease was eighty- 
eight, so that two out of three cases, nearly, were fatal. 

Dr. Collins says, at page 390, "The extreme difference of opinion, 
and the very opposite measures recommended by practitioners, arise, 
chiefly, I am satisfied, from their treating every variety of puerperal 
fever as one and the same disease, whereas, there is, perhaps, not 
any other which exhibits a greater diversity of character, in different 
situations, and even in the same situation at different periods. In 
some, the fever is accompanied by symptoms indicative of the most 
active inflammation, such as to forbid the least delay in the free use 



572 PUERPERAL FEYER. 

of venesection, and the decided employment of antiphlogistic mea- 
sures. This form of disease, which is by far the most manageable, is 
generally met with in private practice. Puerperal fever, when epi- 
demic in hospital, is directly the reverse ; at least, in four epidemics 
which I have witnessed, the symptoms were usually of the lowest 
typhoid description, the pulse being so feeble and indistinct as to 
make you dread, in many, even the application of leeches; the patients, 
in several instances of this form of the disease, exhibiting somewhat 
the appearance of those laboring under cholera." Dr. C. informs us, 
also, at p. 392, that when he was assistant, in 1823, the fever raged to 
an alarming extent, and that in that epidemic the Master used venesec- 
tion with great frequency, and in the promptest manner. The effect 
on the patient, and on the mortality, convinced Dr. C. fully of the 
inexpediency of adopting this treatment. 

I have cited this most respected author, in order that the reader 
may be put in possession of some of the grounds of his objection to 
the employment of the lancet in epidemic puerperal fever, and I admit 
that his authority is deservedly very high. But I take the liberty 
to remark, that he gives us no details of the epidemic in 1823, and 
w r e are left in the dark as to the mode in which the antiphlogistic 
treatment was carried out. We are not told the quantity of blood 
taken in the cases which proved fatal. This is a circumstance to be 
regretted, since the friends of the practice agree in opinion, that a 
very large bleeding only, is to be depended on in the cure, and that, 
early in the disease, within six hours from the commencement of the 
malady. 

It is highly important for the reader to observe, that Dr. Collins 
lost fifty-six out of eighty-eight patients, under a system of treatment 
which consisted in giving, at the beginning, a draught composed of 
castor oil and spirits of turpentine, of each half an ounce. In some 
cases, twice the quantity above mentioned was given. " Where the 
state of the patient was such as to encourage a general bleeding, we 
used the lancet ;" but the doctor is satisfied, that in hospital it is bet- 
ter to apply three or four dozen leeches, and place the patient in a 
warm bath. Stuping the belly with flannels wrung out of water as 
hot as the patient can bear it, is another favorite remedy with him. 
This, followed by leeches after from four to six hours, is highly recom- 
mended. In some cases, from ten to sixteen dozen leeches were used. 
This was followed by the very free use of calomel and ipecacuanha, in 
doses of four grains of calomel and as much of ipecacuanha, repeated 



PUERPERAL FEVER. 573 

until, in some instances, the patient had from three to five hundred 
grains of the mercurial medicine. 

Such are the most marked features of a plan which, at most, has 
not great success to boast of, inasmuch as fifty-six out of eighty-eight 
cases were fatal. 

At page 399, commences an account of cases of recovery from 
puerperal fever. They appear to have been taken indiscriminately 
from the record of successful cases. Of these cases, amounting to 
nine in all out of the twenty-nine cases, only two were bled, and they 
each lost fifteen ounces from the arm. The others were treated with 
leeching, &c. 

At page 424, commences the account of fatal cases of puerperal 
fever. These also seem to be taken indiscriminately from the record, 
and are eighteen out of the whole number of fifty-nine fatal cases, of 
which only one was treated by venesection. She was leeched the 
first day, and again in the night, with eight dozen leeches in all. On 
the second day, she lost, at two bleedings from the arm, forty-seven 
ounces of blood, and was leeched afterwards. In all, she lost, by 
venesection, forty-seven ounces, and had fourteen dozen leeches, five 
warm baths, four hundred and sixty grains of calomel, and twenty- 
three grains of opium, constant stuping, and occasional draughts of 
castor oil and turpentine. 

In regard to this case, I have to remark, that it does not present a 
fair specimen of the value of venesection in puerperal fever; — it was 
resorted to too late, for nothing can save a patient if the disease is 
allowed to get fully in possession of the tissues before it is properly 
attacked ; and the other seventeen cases of mortal termination are 
equally useless as evidences of the impropriety of the lancet as a 
remedy, since it w T as not employed in one of them. If the woman, 
who w-as so freely bled, and afterwards bore leeching, had been so 
well blooded on the first day — what would have been the result ? 
Leeches and calomel, it is true, were freely resorted to, but I am 
constant to the opinion that they are unw r orthy of trust, as prime 
agents, in this most violent and destructive disorder. I have taken, 
perhaps, a liberty with Dr. Collins's work on this occasion ; but I 
feel assured that a gentleman so candid as he, and occupying so 
exalted a station, will look, should it ever meet his eye, with indulg- 
ence upon an opinion which, while it differs from his own, does not 
disparage his great, admitted, and acknowledged merits towards the 
entire profession — merits which I gladly avail myself of this oppor- 
tunity to proclaim. 



574 PUERPERAL FEVER. 

So great is the influence exerted by peritonitis upon the san- 
guiferous apparatus that, even where we succeed in effecting a most 
hopeful and flattering reduction of the pulse by a first bleeding, the 
blood-vessels soon come to be excited again, and the torrent of the 
circulation sometimes resumes its violence in an hour, or even less. 
Such a reaction should be met and quelled by repetition of the bleeding 
again and again, until it is deemed no longer needful or safe to abstract 
blood. When the power of the heart's contraction is sufficiently 
abated to cause it to propel its blood into the aorta with a gentler and 
more healthful momentum, the capillaries, which are the seat of the 
inflammation, will become capable of throwing off the masses of blood 
which have oppressed them, and the constitutional disorders that 
arose from, and then progressed pari passu with, the peritonic irri- 
tation, will subside as it subsides, and disappear as it disappears. 

Among the most sensible and philosophical treatises on puerperal 
fever that have appeared of late years, I look upon the work of the 
younger Baudelocque as one of the most to be esteemed. This was 
a prize production, crowned by the Royal Society of Medicine of 
Bordeaux. Dr. Baudelocque, after examining the objections of nu- 
merous authors to the use of the lancet as a prime dependence in the 
treatment, and especially to the employment of it at any other than 
the earliest period, cites, at pages 312 and 313, two cases from 
Delaroche, in confirmation of the propriety of trusting to venesection, 
whenever the symptoms clearly call for it. He says, 

"Be this as it may, while I acknowledge that nothing absolute can 
be determined as to the stage beyond which the lancet is no longer 
admissible; that we must pay due regard to the intensity of the dis- 
ease, the rapidity of its progress, and the effects obtained from the 
antecedent treatment ; I cannot but recommend, along with the authors 
heretofore mentioned, that recourse should be had to bleeding as soon 
as possible after the commencement of the attack; and I am thoroughly 
convinced, that the loss of a few hours is sufficient to render fatal 
an attack of peritonitis over which an early bleeding would have 
triumphed." 

M. Baudelocque speaks so well on this subject, that I cannot with- 
hold the following paragraph, which is worthy of all praise. At page 
315, he says: 

"The utility of venesection being once allowed, it is important to 
consider the quantity of blood that is to be drawn. Setting aside some 
circumstances, of which I shall speak presently, I believe that the 
sanguine evacuations ought to be very abundant. They ought to be 



PUERPERAL FEVER. 575 

effected in such a manner as to arrest the march of the malady, to 
make it miscarry, if one might use such a phrase, to prevent it from 
reaching a second stage. Perhaps the reason why the proper results 
of venesection have not been in some cases obtained, is that the ope- 
ration has not been done as above recommended. Considering the 
violence with which the disease attacks, and the extent of surface 
that becomes inflamed, one is easily convinced that success will not 
follow the abstraction of a few ounces of blood. The most that could 
be expected in that way, would be to lessen for a moment the violence, 
and retard the progress of the peritonitis, which soon rouses itself to 
move on with augmented speed." 

Again, at page 317, he says, 

" As to the feebleness of the woman, great care ought to be taken 
in order not to be misled by the state of the pulse. Its very great 
frequency, its smallness, are no motives for the proscription of vene- 
section. The pulse should be compared with the commemorative 
circumstances. We ought to bear in mind that one of the characters 
of puerperal peritonitis is this very frequency of the pulse. It may 
be contracted, not well developed, small and concentrated; but at the 
same time it is hard. There is great danger of being led into error 
by this pulse, which is found to become developed, and to lose its 
frequency, after the use of the lancet, and sometimes even during the 
flow of the blood." 

Dr. B. does not at all think that the occurrence of puerperal peri- 
tonitis in hospitals forbids the employment of bleeding as a remedy. 
See his remarks at page 318, which it is quite refreshing to read after 
so much false doctrine as we have had lately upon the management 
of this dreadful disease. 

There are no considerations relative to the treatment of puerperal 
fever, that I regard as claiming to be compared in importance with 
those that concern the use of blood-letting; yet, as it is not possible 
for me to give, in this work, my views, and the reasons for them, 
at full length, I shall say no more here upon the use of the prin- 
cipal remedy. I beg to refer the reader to the article on puerperal 
fever in my "Letters to the Class" — Letter XLI. — but I shall go now to 
the explanation of some circumstances which I think deserving of the 
reflections of the Student, and the most careful observation of the 
practitioner. 

One of the early symptoms of a peritonitis is flatulent distension of 
the bowels, or tympanitis. It is a source of infinite mischief, and 
very difficult of removal. Tympanitis consists in inflation of the 



576 PUERPERAL FETER. 

intestinal tube, and not in the inflation of the peritoneal sac. as some 
are inclined to suppose. The air of which the swelling is composed, 
is extricated from the food or drinks of the patient while in a state 
of fermentation — a fermentation that could not exist except where the 
digestive force is impaired, but which force is necessarily impaired 
where the pulse is at 130 or 140. and where the alimentary tube is 
invested by a peritoneal coat — already a prey to active inflammatory 
disease. But not only is the digestive force greatly impaired ; the 
alimentary tube, whose outer investment consists of peritoneum, re- 
fuses to contract ; the gases that are developed simply distend portions 
of the tube, whose muscular fibres, like all muscles whose integu- 
ments are inflamed, either refuse to act, or act so feebly as to suffer 
the canal to be puffed, or completely blown up, like a bladder, by the 
lateral pressure of the gases of the bowels. In a puerperal woman 
with peritoneal fever, it is not uncommon to find the abdomen as 
large as at the seventh or eighth month of gestation, from inflation of 
the bowels. They become so tense with the tympany, as to resound 
upon percussion like a drum. They in this state prevent, in a mea- 
sure, the play of the diaphragm, whose concavity is at the same time 
lined with an inflamed peritoneum, that in a degree cripples its power, 
and the patient soon begins, on these accounts, to have dyspnoea, with 
panting respiration, while the capillary system of the whole intestinal 
canal, which is put upon the extremest stretch and tension, grows 
rapidly less and less able to get rid of its load of blood by any other 
process than effusion, I have seen some women dying with child- 
bed fever, who sank rapidly, and evidently more rapidly, from the 
great degree of irritation occasioned by the tympanitic distension of 
the bowels, their respiration being not dissimilar to that occasioned 
by hydrothorax. 

In all febrile affections, a tympanitic distension of the alimentary 
canal is greatly to be deprecated, and in none more than that of which 
we are speaking. In peritonitis it adds new dangers to those which 
are already so imminent, and should be carefully obviated by proper 
remedies. Now it may be said that there could be no tympanitis in 
a case in which the peristaltic fibres of the bowels should continue 
in the regular exercise of their functions : but where a tract of the 
jejunum or colon is fully inflated, there is, for the time being, a total 
suspension of the peristaltic movement of the muscular fibres of that 
portion of the tube ; they being in a quasi state of paralysis, or inac- 
tion at least, so as to permit the extricated eases of the canal to inflate 
it. In order to obviate this evil, we are obliged to make use of ape- 



PUERPERAL FEVER. 577 

rient medicines, or even purgative doses, to stimulate the peristaltic 
fibres into a degree of activity sufficiently great to enable them to ex- 
clude or pass onwards the gases with which they are distended. For 
this end calomel and opium, followed by moderate doses of oil, are 
highly appropriate — or we can rely on doses of infusum rhei, with 
addition of small portions of potash or soda — or magnesia with mint- 
water — or a solution of manna, with addition of magnesia, and oil 
of anise-seed. 

I have on many occasions found the introduction of a catheter into 
the rectum capable of drawing off the w T hole of the air of the tym- 
pany. A most distressing tension of the abdomen, after delivery by 
the Csesarean operation, was suddenly and completely relieved by 
the introduction of a female catheter a few inches into the rectum. 
The bowel had not power to overcome the sphincterian contraction, 
and the patient was dangerously inflated in consequence ; the catheter, 
when passed above the sphincter, permitted the gas to rush out of 
the tube with a hissing noise. It is an excellent resource, unattended 
w T ith pain or the least inconvenience. See the case of Mrs. R. at p. 
534 of this volume. 

I am far from desiring to be considered in favor of very active 
purging as a remedy in peritonitis. It would be obviously improper 
to enter upon the management of a case of the malady without pro- 
curing a sufficient evacuation of the feculencies that are generally 
accumulated in the bowels of lying-in-women: that should be always 
attended to; and when the physician is satisfied that they have been 
removed, he should abstain, as a general rule, from the use of strong 
purges; but if the tympanitic state of the patient requires it, he should 
by no means withhold the aperient medicines which have been re- 
commended, or even the strongest purgative doses. 

I have seen cases of puerperal peritonitis in which, very soon after 
the invasion of the malady, the belly became frightfully tympanitic ; 
an injection will serve under such circumstances to evacuate the con- 
tents of the rectum, and perhaps of the lower part of the colic sigma, 
giving rise to a copious feculent dejection. But, from this time forth 
it has been utterly impossible, by any therapeutical or chirurgical 
process, to procure another evacuation: the patient sinking into the 
arms of death, and perishing evidently from this extraordinary degree 
of meteorismus. The most active enemata, composed of senna, of 
jalap, of common salt in large quantities ; the introduction of the 
stomach tube far into the bowel ; large doses of calomel, infusion of 
senna, or croton oil, or elaterium, proved alike inadequate to the ex- 
37 



578 PUERPERAL FEVER. 

pulsion of the distending gases. It is desirable that the Student, who 
■will in his career have probably some occasions to be baffled as well 
as surprised at the failure of his therapeutical resources in such cases, 
should have a clear view of the cause of his embarrassment. Let 
him roll up a sheet of paper in a cylindrical form, so as to represent 
a portion of intestinal tractus, and then let him bend it at an acute 
angle, and he will see that the calibre of the bowel bent in this way 
is as effectually closed as if a ligature had been passed around it and 
tied. Let him further consider that while the lateral pressure of the 
gases has the effect enormously to distend the conjugate diameter of 
the intestine, their pressure also tends to elongate the bowel, which, 
as it cannot go forth from the abdomen, is compelled to turn short 
upon itself to become angulated, and thus it produces an angulated 
stricture, like that which he makes by bending a cylindrical roll of 
paper at an acute angle. I have seen three such angulated strictures in 
the colon of a young person, who died in this manner tympanitic; 
and I had the misfortune in 1848 to witness the loss of a most valued 
patient, a loss which I feel convinced might have been avoided but 
from this angulation of the colon. 

It is frequently found, that, even in those cases where we feel as- 
sured the peritonitis has received, by the lancet and other means, an 
effectual check; where the pain is all gone, and even the soreness 
removed, the patient continues to have fever, which may last many 
days. Under these circumstances the use of James' powder, or the 
golden sulphur of antimony combined with nitre and calomel, is of 
the greatest value. These medicines very generally give rise to co- 
pious diaphoresis, which may be maintained by draughts of warm 
herb tea, such as the balm, or sage, elder or linden blossoms, or by 
copious draughts of barley-water, and a careful adjustment of the 
bed-clothes to the condition or circumstances of the patient. 

During the whole period characterized by active inflammatory symp- 
toms, the diet ought to consist of barley-water, very thin gruel, or 
arrow-root, and such like articles. A greater degree of indulgence 
may be allowed after the fever has quite disappeared. 

Rest, in a recumbent posture, is one of the essentials of the suc- 
cessful management of the case. The nurses should be forbidden to 
raise up the patient even in bed — for if an early getting up from bed 
may serve as the exciting cause of the disorder, it would surely be 
very dangerous to get into a vertical or sitting posture while the in- 
flammation is in full activity. 

For the most part the lacteal glands do not secrete much milk in 



PUERPERAL FEVER. 579 

women in peritoneal and metritic fevers. It is always a hopeful 
sign when the breast continues to be full under'this disorder; neverthe- 
less, the secretion of milk gives no assurance of safety. 

The lochial discharges are also very much diminished, and some- 
times wholly disappear during the greatest intensity of the malady. 
Tepid vaginal injections of mucilage, of flaxseed, or of milk and 
water, may here, with prospect of benefit, be made use of, where the 
patient can bear so much handling. The discharges which are 
checked or suspended, during the onset and greatest violence of the 
complaint, re-appear upon its decline or cessation. 

Blisters are, by some practitioners, held as favorite applications in 
puerperal fever. I doubt not they may, in proper circumstances, con- 
tribute greatly to the safer and more speedy cure of the inflammation; 
but I think I have seen blisters applied too soon in some cases, and 
I have reason to suppose that, if not properly timed, they are capa- 
ble of adding to, instead of diminishing, the constitutional disturb- 
ance, already too great. If applied very early, they increase the fever 
and irritation, and continue to be in the way of other more useful 
remedies; they confound the diagnosis — which should be often re- 
peated — by rendering the practitioner unable to discriminate between 
the pain produced by the cantharides and that arising from the inter- 
nal disorder, which is greatly to be deprecated, since his opinion and 
practice in the case should be very much governed by the degree of 
pain — as it is in pleuritis. A bUster, applied after a due reduction of 
the force of the circulation, and an ascertained diminution of the pain 
and soreness of the belly, may haply bring about a resolution in 
cases which, but for the well-timed prescription of such a remedy, 
would tend to a fatal effusion. 

I do not think that the malady is at all disposed to result in gan- 
grene or mortification. The affected parts are too important and too 
numerous to be the subjects of such terminations; the patient dies 
before they can be effected. The adhesive inflammation is found to 
have exerted its salutary power in some of the examples; but the ad- 
hesions are very partial, the far larger portion of the membrane hav- 
ing poured out vast quantities of a sero-puriform liquid, containing a 
great abundance of flaky matter, which appears to consist of coagu- 
lated albumen, and which is found floating in the fluid contained in 
the peritoneum, or adhering like a croup membrane to the peritoneal 
surface of the bowels, liver, stomach, etc. 

A woman who labors under an acute peritoneal fever is generally 
found lying on the back, with the knees drawn up ; the hands are 



580 PUERPERAL FEVER. 

rarely to be seen crossed on the abdomen — they are laid by her side, 
or across the breast, or they are employed in holding up the bed- 
clothes, whose weight is apt to give pain if pressed on the belly. 
Every attempt to put down the legs, and to draw them up again, or to 
rotate the legs, is productive of pain, because there is implied in such 
motions a contraction of the psoas and iliacse internee muscles, as well 
as the recti and oblique muscles of the belly; but the contraction 
of any one of these muscles occasions a change of relation of parts 
of the inflamed peritoneum. Efforts to cough in like manner pro- 
duce poignant distress. The woman, therefore, moves unwillingly. 
She lies remarkably still, and if affected with jactitation and restless- 
ness, she expresses it only by flinging her arras about, and by fre- 
quent rotations of the head. She always endeavors to keep the 
abdomen and lower limbs quiet; for she learns that every movement 
of them is distressingly painful. Hence the mere decubitus is im- 
portant as a diagnostic sign. 

To find an improvement in the patient's ability to move herself, 
with a corresponding improvement in the circulation, is of the most 
favorable augury ; but to observe the pulse increasing in frequency 
while it also becomes more feeble, with diminished heat of the mem- 
bers and augmented heat of the body; to discover a disposition to 
singultus, with an eructation of fluids into the mouth, an anxious ex- 
pression of countenance, high and frequent respiration, with increased 
ability to move the legs, and diminished pain on pressure, is to 
perceive the cessation of inflammation of the peritoneum; but it 
has ceased not by resolution, or a return to health — it has come to 
one of its natural terms in effusion. The inflammation is at an end, 
and the patient begins to die. It would seem that the forces of the 
living economy have exhausted themselves in the struggle with this 
malady, and, though they conquer it at last, they are themselves de- 
stroyed in the moment of victory. There soon comes on a vomiting, | 
or rather a frequent eructation or gurgitation of fluid, green at first, 
and at length black; the patient mutters, she picks the bedclothes, 
she clutches atmusccevolitantes; the diaphragm labors in vain to carry j 
on the work of respiration ; the hands and feet acquire a livid hue, and 
are clammy; the pulse becomes a thread, it ceases in the wrists — and 
she dies, probably in the act of regurgitating from the stomach the last 
draughts which the anxious hand of friendship or love has tendered 
as a solace or a hope. It is altogether a most melancholy scene ; for, 
connected with all the moral distress which such a fatality lavishes 
on relatives and friends, there is generally a sharper pang for the 



PUERPERAL FEVER. 581 

hapless infant, which, deprived at the moment of opening its eyes 
on the great theatre of the world, of the needful help of its mother, 
is destined to bear for years the bitter fruits of her death. There is 
scarcely a case of disease terminating in the decease of the patient 
which produces such a general sympathy as this — and indeed all those 
which occasion the loss of patients in child-bed. 

I am very sensible that I have made but a slight sketch of puerperal 
fever. It is a subject that could be better discussed in a volume than 
in a few pages ; but I have preferred saying a few words upon the sub- 
ject, even at the risk of making a very meagre article, if I could, by 
this means, bear my testimony against every doctrine which shall teach 
that this most acute, extensive and dangerous inflammation is to be 
combated by any means short of the most signal and active of those 
which are called antiphlogistic. 

In taking charge of ordinary cases of illness, the patient and his 
friends are already aware of threatened danger: in taking charge of 
an accouchement, the physician assumes the conduct of a health- 
ful and truly physiological process. A woman lies down on the lit 
de misere in order that she may give birth to a child ; an attack of 
puerperal fever too often converts it into her bed of death. A man 
goes to his bed in fever under the apprehension of approaching death; 
he is rescued by the physician, but the accouchee who perishes is 
lost. There is a great difference in the sentiment connected with the 
cases. 

Since this chapter went to press I received a letter from Dr. Collins, 
dated Merion Square, Dublin, Jan. 2d, 1849. 

I am led by my desire to show my profound respect for that dis- 
tinguished gentleman, to do what perhaps I have no right to do in 
publishing a portion of his private letter to me. Very certainly I 
desire in doing so only to allow that author to speak for himself to my 
reader, because I have ventured to differ from him in my views as to 
the application of a vehement antiphlogistic method in child-bed fever. 
In his note to me, Dr. C. points out the difference betwixt such cases 
as Gordon and Lee treated, and such as came under his care at the 
Dublin Lying-in-Hospital. It appears to me that I ought to be par- 
doned then for taking this public liberty with a private letter, which, 
though it refers to another work of mine, yet has also a relation to 
these pages, in which I could not avoid setting forth opinions similar to 
those I had expressed in the volume to which he alludes. The Student 
ought to procure and read Dr. Collins' work, and then he will be able 
to judge for himself, for he will have the observations as well as the 
cases to judge by. The following is the letter of Dr. Collins. 



582 PUERPERAL FEVER. 



"My Dear Sir: 



Merio^t Square, Dttblix. 
January 2d, 1849. 



At pages 609-10 you compare the mortality in puerperal fever 
under my treatment, and that of my distinguished friend, Dr. Robt. 
Lee of London; to prove the greater success, where general bleeding 
had been more frequently adopted by him. 

The great and markedly distinguishing feature between Dr. 
Lee's cases and mine, has, however, been overlooked; as mine were 
all Hospital Patients; whereas his were all treated at their own 
dwellings. This was also the case with the late Dr. Gordon's patients, 
to whom you so deservedly allude. 

The disease with us, and I believe universally, is as different in 
hospital and out of hospital, as it is possible to imagine. 

Please look to my observations, pages 390-1-2, &c, where I have 
stated the patient to be little more than shadow, and to exhibit the 
appearance of those laboring under cholera; so as to make us dread 
even the application of leeches. The fever is of the lowest typhoid 
character, with the pulse so feeble and indistinct, as to totally prohibit 
general depletion. This form of the disease is singularly intractable 
and truly fatal; whereas the inflammatory form of puerperal fever, 
such as usually met with out of hospital, may be treated with consi- 
derable success. 

I have a work in the Press at present containing the results of the 
late Doctor Joseph Clarke's private practice in Dublin, for a period 
of nearly fifty years, including 3847 births, which I consider of great 
value, as hitherto we have no minute data relative to patients in the 
highest ranks of society. 

I have given in it an extremely interesting correspondence between 
Dr. Clarke and some eminent professional brethren, on the occurrence 
of puerperal fever in private practice, in London, Dublin, and Edin- 
burgh. 

I should have stated that few physicians have witnessed the results 
of general bleeding to a greater extent than I have done, as the master 
of the hospital who preceded me, and to whom I was Assistant, was 
a strong advocate for it ; but the mortality was so frightful, he was 
forced to abandon it. He bled instantly and copiously, but with the 
most fatal results. 

Such is the character of almost all our hospital epidemics." 



ATRESIA VAGINA. 583 



CHAPTER XX. 



OF ATRESIA VAGINJE. 



The obstetric physician will be likely, in a long career of practice, 
to encounter cases of atresia of the genital organs. 

Some of the cases are capable of giving rise to extreme distress, 
and even of bringing the life of the patient into danger. 

Atresia, or closure, or obturation of the vagina or cervix uteri, may 
occur as a congenital malformation, or it may take place in infancy 
or childhood, and may even occur in persons who have borne children. 

The obturation may be discovered to exist in any part of the canal 
of the vagina, whether at the vulva or whether at the uterine extremity, 
or whether midway of the tractus of the tube. 

In the congenital cases there may have been fault of development, 
the mucous tissue having totally failed to be constructed. In infants 
or young children a slight vaginitis might suffice to determine the 
cohesion of the opposite w T alls of the vagina, the occurrence remaining 
undiscovered until a full puberty, or the state of marriage, should lead 
to the disclosure of the fact. 

To show that it may occur in women w r ho have borne children, I 
refer the Student to the following case. 

Case. — A woman, from a distant part of the country, came to the 
city, in the spring of 1837, in order to consult Dr. Randolph, who was 
good enough to invite me to see the patient with him. Her story was 
as follows. More than two years have elapsed since she gave birth 
to a healthy child ; the labor was extremely rapid, so much so, indeed, 
that the infant was born before the physician could reach the house. 
The after-birth did not come away for an hour, during which time there 
was flooding. It was at length removed by force. The woman be- 
came very w r eak. In a few days she was attacked with inflammation 
of the vagina, accompanied with enormous discharges of matter, and 
great thick pieces of flesh, to use her own account. She was never 



584 ATRESIA VAGINA. 

examined by her physician, who, however, directed washes, injections, 
etc. After a long and exhausting hectic, attended with extreme 
emaciation, her discharges grew less copious, and she gradually, at 
the end of some months, got well. There was, however, no vagina, 
not even a cul-de-sac; there was simply the genital fissure. Of course, 
no catamenia could appear; but, after several months of good health, 
she began to complain of pain or misery in the hypogastric and pelvic 
regions. The pains recurred with periods of a month, and having at 
length become intolerable and persistent, she found her health de- 
clining, and came, as before said, to consult that able and eminent 
surgeon, Dr. Randolph. 

There was a tumor in the hypogastrium, which reached half-way 
up to the navel ; it was of a firm and resisting feel, not unlike a con- 
tracted womb soon after delivery. As there was no vagina, the finger 
was passed into the rectum, where it came in contact with the same 
tumor, which seemed to occupy the excavation as it is occupied by a 
child's head, filling the cavity entirely. Upon separating the labia, 
there was nothing but the genital fissure ; there was no way for a 
common probe to pass upwards. A sound was introduced into the 
bladder, and retained there until a finger was also introduced into the 
rectum: the only texture that separated the finger and the sound 
seemed to be, upon careful examination, the walls of the urethra and 
the coat of the bowel; there was no vagina to be felt. Hence Dr. 
Randolph and I agreed in opinion that the vagina had been wholly 
destroyed by the sloughing process which took place shortly after her 
confinement. We entertained no doubt as to the nature of the tumor 
that occupied the pelvis and lower part of the abdomen: it was the 
womb hermetically sealed, and retaining in its cavity the accumulated 
menstruations of nearly two entire years. 

After much diligent search, we were unable to discover the cervix, 
or os uteri; but we supposed they might possibly be turned upwards 
towards the top of the pubis, so as to elude any investigation made 
through the rectum alone, the only possible way of making research. 
No vestige of a vagina was discoverable by the taxis ; nevertheless, 
supposing it possible that the whole tube might not have been de- 
stroyed, and that haply its upper extremity might be reached by the 
bistoury, Dr. Randolph operated with a view to make an artificial 
vagina, and discover the remainder, if any, of the original one. 

Introducing a strong metallic staff, slightly curved, into the bladder, 
he took his seat in front of the patient, who laid on her back, with 
the knees drawn up and separated. I held the stafT firmly, while, 
with the forefinger of his left hand in the rectum to serve as a guide, 



ATRESIA VAGINA. 585 

by horizontal strokes of the bistoury he dissected the tissues betwixt 
the rectum and urethra, and carried his incisions up very nearly to 
the substance of the womb itself, without having wounded either the 
rectum or the urethra: when he had completed his incisions, the 
whole finger could be passed upwards to the bottom of the cul-de-sac 
he had formed by so skilful and accurate a use of the bistoury. 

In consequence of our uncertainty relative to the situation of the 
os uteri, and from his having successfully removed so considerable a 
portion of the barrier which opposed the escape of the contents of the 
uterus, Dr. R. suspended his operation at this point with the following 
views. 

It w T as resolved to keep the passage open by the use of a bougie, 
made as light as possible, and of a size sufficiently large. The 
bougie was made of silver gilt, about four inches in length, and as 
large as the thumb, its weight not more than two drachms, being hol- 
low. We indulged a hope that, by using this bougie a few months, 
the progress of the case would be such as to bring the os uteri to the 
extremity of the instrument, by means of the increasing expansion of 
the uterine globe, and that the contents of the womb would discharge 
themselves into the artificial vagina, or that they might be discharged 
by a future incision. The lady returned to her own country, and 
after an absence of three months came back to the city, still suffering 
under the same misery, with an increased magnitude of the uterus, 
but without having had any discharge from the vagina. She had 
constantly worn the bougie. Upon examination, we found that the new 
vagina was now covered by a smooth surface, resembling a mucous 
membrane ; the upper end of the bougie, when withdrawn, was co- 
vered with a sort of muco-purulent matter, tinged with blood. The 
sufferings of the patient from the distension of the womb w T ere very 
great, and it was on that account agreed to puncture the organ in 
order to draw off its contents. On the eighth day of July, 1837, Dr. 
Randolph, and Dr. R. M. Huston, who had been invited by us to wit- 
ness the operation, met me at the lodgings of the patient. 

The tumor, felt through the vagina, was hard and resisting, like 
an enlarged ovarium ; it was softer and the walls thinner, when ex- 
amined through the rectum. At Dr. Randolph's request I now made 
use of a curved trocar, enclosed in a canula, in order to puncture the 
womb. The trocar was about five inches in length, and of the size 
of a small writing-quill. The patient was laid on her back near the 
edge of the bed; I introduced the forefinger of the left hand into the 
rectum, and having directed the end of that finger to a part of the 



586 ATRESIA VAGINiE. 

tumor that felt most yielding, I carried the point of the trocar along it, 
and having given it a direction as nearly as possible perpendicular to 
the surface of the tumor, pushed it through the resisting tissue until 
I found it had freely entered the cavity of the uterus; the trocar 
was now withdrawn, leaving the canula in place. There issued 
from the open end of the tube a dark red viscous material, with- 
out odour, of the consistence of meconium, and as adhesive as that 
substance. The puncture was scarcely felt. In twenty-four hours, 
during which the canula was permitted to remain in situ, pro- 
perly secured, about twenty-five ounces of this fluid were discharged: 
the uterine tumor had disappeared from the hypogastrium, and the 
mass, as felt in the rectum, was greatly reduced in size, and far more 
movable. As all the liquid seemed to be now evacuated, the canula 
was withdrawn : no discharge followed its withdrawal. The patient 
had no symptoms attributable to the puncture. She rapidly recovered 
her strength, and left the city with renovated health, and nearly free 
from the misery which had so long embittered her existence. In the 
course of about a month after returning to her home, she had a very 
copious discharge from the vagina, of a fluid of a consistence similar 
to that which had flowed through the canula, but of a whitish color, 
after which her health greatly improved. On Tuesday, the 12th of 
December, 1837, the patient, while on her way to the city, for the 
purpose of further advice, discharged from the vagina about twenty- 
five ounces of a substance in all respects similar to that which passed 
off when I used the trocar to puncture the womb. I w 7 as informed 
in 1841, that she has menstruated regularly and has recovered a 
very comfortable health. 

I refer to the ninth letter, page 83, of my " Letters to the Class," for 
a fuller account of cases of obstruction of the vagina, than it would be 
possible for me to introduce into the present work. 

Before I close this article, however, I shall take occasion to mention 
that a careless inspection of the surfaces of the bottom of the vulva 
might, in some instances, mislead the practitioner as to the existence of 
an atresia. A lady, already four months married, was presented to 
me for examination on account of incapability of consummating the 
marriage rite. Upon inspecting the surfaces, I found in the usual 
place, at the bottom of the vestibulum, to wit — what I supposed to 
be the orifice of the urethra; while the tissue falling downwards and 
backwards within the genital fissure, seemed to be the anterior wall of 
the vagina which had cohered with the posterior wall. The apparent 
fossa naviculars w T as shallow, and upon stretching it downwards, some 



ATRESIA VAGINA. 587 

appearances of a rapheof cohesion was discovered, extending in a semi- 
circular direction nearly up to the supposed orifice of the urethra. In 
order to relieve the patient, I made some slight incisions into the sup- 
posed raphe, thinking thereby to destroy adhesions and make an opening 
into the vagina. But owing to the extreme restlessness and agitation 
of the patient, it was impossible to proceed with the proposed opera- 
tion. On a subsequent occasion it was ascertained that the supposed 
orifice of the urethra was the natural opening at the top of the hymen, 
w r hich was a very dense, fleshy membrane, an eighth of an inch 
in thickness. The true orifice of the urethra was afterwards found 
concealed in a small fold just above this aperture. It was proved to 
be the urethra bypassing a catheter through it into the bladder, while 
the inferior aperture, scarcely larger, permitted the introduction of 
the catheter into the vagina. The hymen was destroyed by a stroke 
of the scissors, and the vagina, an exceedingly narrow one, subse- 
quently dilated with the gilt bougie. 

I have never seen so deceptive a case, and I cite it here in order 
to put the Student upon his guard against the mistake which I com- 
mitted. 



588 ERGOT. 



CHAPTER XXI. 

ON ERGOT. 

I am inclined to say a few words as to my opinions upon the secale 
cornutum as a therapeutical agent of great power in labors. It is 
needless for me to say anything here as to the nature of this substance, 
which is fully described in a book universally in the hands of the phy- 
sicians of this country: I mean "Wood and Bache's Dispensatory." 
There is also a very full account of it in Cazeaux's new work, Traite 
Theorique et Pratique de VArt des Accouchemens, commencing at p. 
395. I have had occasion many times to witness, during a long-con- 
tinued practice of midwifery, the effects of the secale, whether ad- 
ministered with my own hands or by those of others. It has frequently 
been the subject of conversation among my medical brethren here ; 
and I feel very much persuaded that the general opinion of those gen- 
tlemen is one that may be stated as distrustful of the ergot, not as to 
its want of power, but as to the dangerous nature of that power, whe- 
ther as regards the woman or the child she is bearing. 

The late professor, Dr. James, was perhaps less fearful of its mis- 
chievous qualities than Dr. Dewees ; the former resorting to it not 
unfrequently when a failure of power existed, and the latter always 
preparing against its use the most careful array of objections, except 
under circumstances pointed out in his "Midwifery." 

Those who have perused the little volume published a few years 
ago by a Dr. Michel, an English practitioner, who w T rites in favor of 
the use of ergot, will feel surprised to witness the audacity with which 
one person exhibits it at the very onset of labor, or as a preparative 
or aid in turning, etc., and the extreme precaution recommended by 
Dr. Dewees, who never sanctions its use as an aid to expulsion, unless 
the os uteri is fully dilated, and the child already pressing out the 
perineum. 

Within a few years a good many persons continued to doubt whether 
the article really possesses the singular and sole quality of exciting 



ERGOT. 589 

the contractions of the womb. I have not lately heard of any objec- 
tions to it on that score, but they rather arise from the uncontrollable 
force which it awakes in the womb, leading, as is supposed, to dan- 
ger of lacerating the organ when the resistance to its expulsive effort 
is too great, and very commonly to the death of the child. 

It is true that I have known laceration of the womb follow the ex- 
hibition of ergot, and have on occasions stood by with fear, and 
expected that horrible result. This is a rare event, however; whereas 
the death of the foetus from the rash exhibition of the medicine is a 
common one, which is reasonably to be looked for, and for the reasons 
which I am about to state. 

In the case of a feeble and attenuated patient, with relaxed and 
weak tissues, whose labor is lingering merely from want of power, 
and not from unnatural resistance, I can imagine that the ergot might 
be safely administered at almost any stage of the labor. But in a 
woman in good health, whose labor is slow for want of proper rotation 
of the head, or rendered^lingering by rigidity of the os uteri, vagina, 
or perineum or vulva, or excessive relative magnitude of the head, 
the greatest degree of consideration should be given to the whole case 
before resorting to the ergot, in order to decide which is preferable, 
the secale, or the forceps or vectis. 

Suppose the child so situated or so large that an enormous force is 
required for its expulsion, and that antecedently to that expulsion 
some changes ought to take place in the direction of the vertex, etc. ; 
no prudent practitioner would blindly urge his patient to destruction 
by giving her ergot, without first changing the direction of the head 
to the required position; and if the soft parts should oppose, by an ex- 
cessive rigidity, the birth of the child, he would by the use of the lancet 
and warm bath, or by stuping the parts, &c, make some prepara- 
tion for the exertion of the terrific energies of the medicine. Let us 
think for a moment upon it. A labor is effected by the contraction of 
the muscular fibres of the womb, aided by that of the abdominal mus- 
cles. If all the power employed in a labor could be accumulated in a 
single pain, lasting as long as all the natural pains do, few women pro- 
bably could escape with life from so protracted an agony, except that 
small number who are met with, and whose organs, happily for them, 
make no resistance, but open spontaneously like a door to let the foetus 
pass out. 

Now the influence of ergot in a full dose is such, that it excites in 
the fibres of the womb a contraction or tonic spasm which is called 
ergotism, and which, when once begun, does not cease until the child 



590 ERGOT. 

is expelled, or until the organ has parted with all its irritability, and 
the spasm ceases from sheer want of power in it to contract. 

This contraction is so great, in some cases, as to split or lacerate 
the womb on the projecting parts of the child, or, what is more likely, 
to tear off the connection between the vagina and uterus, so as to force 
the child through the rent into the belly. Such a pain may last 
twenty minutes or even half an hour, without a moment's suspension. 
Imagine the feelings of the woman. 

By a beneficent law of the economy, the pains of a labor are 
short, not lasting more than thirty or forty seconds in general, and 
returning once in three or six minutes. Under such pains or con- 
tractions, however powerful, the foetus is safe ; for, as soon as the con- 
traction is over, it lies in the womb free from pressure, and the pla- 
centa, which, during the contraction had been violently compressed 
betwixt the womb on which it lies and the child within the cavity — 
that placenta, I say, recovers its circulation, and continues, during 
the absence of the pain, to perform all the branchial offices which 
belong to it. But, if an ergotic pain is produced, to last thirty 
minutes, in a case where the placenta is on the fundus uteri, and to 
be jammed for thirty minutes against the child's breech without an 
instant of relaxation, who can doubt that its circulation is either wholly 
or nearly abolished, and that when the child emerges at last from the 
mother's womb, it will emerge quite dead, or iu a profound asphyxia, 
from the long suppression of its placental circulation? Multitudes of 
children are born dead from this very cause, by the imprudent exhi- 
bition of a medicine, which as certainly excites spasm of the womb, 
as mix vomica does of the other muscles of the body. 

Now what I want the Student to reflect on is this question. Shall 
I in this case give a dose of ergot which will excite a spasm of the 
womb, hoping that spasm will bring the child into the world? Is the 
child ready — is its head through the strait — has its head undergone 
the rotation — is the vertex under the arch of the pubis — is the exter- 
nal organ in a dilatable state — in short, is there anything here that 
could prevent the child from emerging at once, if the whole of the 
contractile fibres of the womb could be thrown into a strong spasmodic 
action? No! Then the ergot may be given; for, if the child begins 
to move as soon as the womb begins to move, it will be born soon, 
and escape the asphyxia which would certainly overtake it, were it 
to remain inside of the body, while a long ergotism should be ex- 
hausted in vain. The power of the ergot is exerted upon the whole 
muscularity of the uterus ; the contractions that take place under 



ERGOT. 591 

the influence of ergotism affect the fibres of the cervix as truly as they 
do those of the corpus and fundus; the question then recurs, shall I 
give ergot in this case in order to produce violent contractions of 
the cervix uteri, not doubting at all that the whole of the cervix will 
be thrown into spasmodic or ergotical contraction, but confiding in 
the superior power of the greater mass of muscular material contained 
in the fundus and body? 

Michel's cases show that when he administered ergot in the undi- 
lated uterus, containing an unbroken ovum, the superior power of the 
fundus and body rapidly overcame even the ergotism of the cervix, 
and many of his patients appeared to have escaped well from the 
rude trials to which he exposed them. There would certainly be 
less danger in administering ergot in a case where the ovum is un- 
ruptured, than in one in which the waters have been already expelled, 
since the uterus, in such a case, could by no means mould itself upon 
the anfractuosities of the child's body. The practitioner who should 
dare to drive the uncovered head of a foetus against a rigid cervix in 
spasm by means of the mad force of ergotism, is, to say the least, a 
most untrustworthy practitioner, one who recklessly exposes his patient 
to the danger of uterine lacerations, and is indifferent to the poignant 
distress which cannot fail to result from such an administration. 

For my own part, I can say, that I rarely give ergot as an expul- 
sive agent: I chiefly employ it at the moment of, or just before the 
birth of the child, in order to secure, if possible, a permanent or tonic 
contraction of the womb, after labor, in women who are known in 
their preceding labors to have been subject to alarming hemorrhage. 
Of this I have before spoken in this work, and shall take occasion 
to speak further of it hereafter. 

Upon the whole, I must say, that I feel far more comfortable, and 
free from apprehensions for the child and the mother, wdien I deliver 
with the forceps, than in waiting the result of a dose of secale cornutum. 

The medicine may be given in doses of twenty or thirty grains of 
the powder, mixed in half a cupful of hot water; or half a drachm 
may be mixed in six spoonfuls of w r ater, of which one may be given 
every ten minutes. I think, however, that when one resolves upon 
using the article, it is best to give at once a good dose of twenty or 
thirty grains. 

A forceps ought to be at hand. In some cases, when the ergotism 
is produced, not the smallest tendency to expulsion appears, but the 
child is held still, under a firm and equable pressure exerted upon 
all the parts of it still retained in utero. It would die very soon if 



592 ERGOT. 

not released. Hence I said a forceps ought to be at hand, to save it, 
if possible, from the fatal grasp of the infuriated organ. 

The use of ergot has very much diminished in Philadelphia in the 
course of the last ten or fifteen years. Few practitioners, when I was 
first engaged in business in this metropolis, were unprovided with a 
portion of ergot, which was given in almost every case of slow labor; 
the number of still-born children, I doubt not, was greatly increased by 
this pernicious practice. At the present day, I think, it is rare for 
the practitioner to carry portions of ergot about his person. 

I advise the Student of medicine to be provided with a sufficient 
quantity of secale cornutum in any case in wmich he is made 
aware of the tendency of the patient to faintness and flooding after 
delivery. I think that no woman, who is known to have a tendency 
to flood dangerously after the birth of the child, should be left without 
its conservative influences. To give ergot some three or ten minutes 
before the child is born, is certainly not to expose it to the least dan- 
ger from the ergotism, for it is extremely rare to observe the thera- 
peutical force of the remedy until from twenty to thirty minutes have 
elapsed after its exhibition : now women who flood after delivery, rarely 
do so within the first twenty minutes, and, as the power of the article 
extends to the vacant uterus, and is perhaps no less forceful there than 
in the gravid womb, a well-timed administration of the drug is almost 
invariably successful in obviating the tendency to hemorrhage. It is 
true that I have exhibited the secale in some instances at the very 
close of the labor for women whom I had known to flood dangerously 
before, and in whom no good effect was produced; but it is still quite 
true that, in the vast majority of instances, and they are very nume- 
rous, in which I have made use of this precaution, my patients have 
been preserved from the alarm, and the exhaustion, and probable 
danger to which I have deemed them exposed ; so that, in fine, I have 
no conviction stronger than this, namely, that the late administration 
of ergot for hemorrhagic patients is salutary and needful. 

I trust that no reader of this work will ever commit the imprudence 
of administering secale cornutum with the view to force a child through 
a too narrow pelvis. I have said already enough, perhaps, as to the 
necessity of ascertaining beforehand the amount of probable resist- 
ance to a successful ergotism, to guard him against so gross a mala- 
praxis. I am painfully aware of several examples of fatal rupture of 
the womb brought on by the furious excitement of ergotism, generated 
in order to overcome the resistance of a contracted pelvis. 

As to the influence of the ergot on the constitution of the female, 



ERGOT. 593 

I am entirely unaware of any poisonous power that it can exert. I 
have seen a few women affected with slight vomiting after its exhibi- 
tion, but was unable clearly to trace the accident as an effect of the 
medicine. 

It appears to me that its sole therapeutic force is exerted in stimu- 
lating the muscular action of the uterus. 

It is sometimes given for the purpose of procuring abortion ; but 
for the most part, happily for humanity, in vain. It is useful to ex- 
hibit it for the purpose of rousing the torpid muscularity of the uterus 
for the expulsion of hydatids, and of the dead ovum or mola; I have 
succeeded in this administration of it. It is highly useful in the he- 
morrhage of abortions, often provoking a speedier expulsion of the 
remains of the ovum, and, when that effect fails, succeeding in arrest- 
ing the hemorrhagic molimen by its power of condensing the uterus, 
of which a philosophical rationale is found in its ability to diminish 
the hyperemia of the uterine circulation. 

To show that it may be taken in large quantities without injury to 
the health of the patient, and at the same time without exciting in 
the least degree the contractility of the child-bearing organ, I shall 
lay before the reader the following case, that of Mrs. R., at the 82d 
page of the 2d edition of "Clinical Midwifery," by Dr. Lee. 

"(Case 29.) Mrs R. again became pregnant about the end of 
December, 1837. 'On the 17th January, the catamenia not having 
appeared, she began taking secale cornutum for the purpose of pro- 
ducing the expulsion of the ovum.' She began by taking twelve 
grains four times a day in infusion. This having produced no effect 
in six days, the dose w T as increased to fifteen grains four times a day. 
In six days more this was increased to a scruple four times a day. 
In six days more this was increased to twenty-five grains without any 
effect. The dose was then increased to half a drachm four times a 
day. Mrs. R. then left off ergot for one week; when she again re- 
sumed it, she took one-drachm doses four times a day for four days, 
and this having produced no effect whatever, she left off taking it alto- 
gether. Mrs. R. therefore took seven ounces of ergot of rye, which 
was all procured at Butler's, Covent Garden. Labor not having fol- 
lowed, I perforated the membranes," etc. etc. 



38 



594 MILK-FEVER. 



CHAPTER XXII 



OF MILK-FEVER. 



The mammary glands, which in the virgin state are small and to 
a great degree undeveloped, participate in the new movements of the 
constitution that are established in the pregnant woman. The tissue 
of the glands begins early to expand, and the breast becomes sensi- 
bly larger very soon after the conception takes place; the areola and 
nipple assume a darker hue, and indeed turn almost black in some 
persons. These changes do not take place without producing a sense 
of soreness or aching of the part. So great is the increase of vital 
force, that some women find a considerable secretion of milk in the 
breast, as early as the sixth, seventh and eighth months; but, for the 
most part, no milk is formed so soon. If a healthy woman should 
miscarry at five months and a half, it is to be expected that her 
breast will fill with milk, within seventy or eighty hours after her 
delivery, and, a fortiori, secretion may be expected if she be confined 
at the sixth month or later. I have seen a woman whose child was 
born at five months and a half who served as a most excellent wet- 
nurse. I have found milk in the galactophorous tubes of a young 
woman, whose body was exhumed for examination by a jury, although 
she had been confined at a little past five months. During all this 
time the organ, though more firm and protuberant than in the non- 
gravid state, does not become positively hard, but is soft and yield- 
ing under pressure; for the increased size is owing more to an in- 
creased deposit of adipose matter on the breast exterior to the fascia 
of the gland, than to the swelling, enlargement or engorgement of the 
glandular tissue itself, at this early stage. Such are the phenomena 
relative to the breast in pregnancy. 

Let us now endeavor to account for them, by a reference to the in- 
ternal structure and uses of the apparatus which nature has arranged 
for the support of the new-born product of the gestation. 

The breast appears at an early stage of the foetal existence, but 



MILK-FEVER. 595 

does not become prominent until the period when the girl is passing 
into the womanly state, and even then the substance of the gland is 
more solid and condensed than when prepared for the production of 
milk. The adipose structure is very abundant upon the breasts, so 
that, in general, fat women have them of great size, without at the 
same time having a larger share of the glandular material than some 
other women of a meagre constitution ; and, indeed, it does not 
appear that the largest breast is to be depended upon for the pro- 
duction of the greatest quantity of milk. A breast of middling size 
is to be preferred in choosing a wet nurse. 

A layer of adipose matter is to be found immediately under the 
skin in dissecting the breast, and this adeps exists there in masses or 
lumps, separated from each other by cellular digitations which unite the 
skin to the parts beneath it, constituting a sort of membranous fascia 
or division, by which the different portions of the gland are made up 
into packets or bundles, and by which, as Sir Astley Cooper says, the 
gland is slung upon the chest. Underneath the fatty layer are to be 
found the lactiferous glands enclosed in their true fascia. The whole 
gland is so formed, as to resemble somewhat a placenta, being circu- 
lar, thinner at the margin than at the centre, and consisting essentially 
in a great number of small grains, the size of millet seeds, which are 
enclosed in separate packets or bunches by the cellular laminse, which 
thus break it up into lobes or nodules, each, as it were, enclosed in a 
cellular fascia. The exterior surface of the whole gland is enclosed 
in a condensed cellular texture, which constitutes a fascia for it, but 
is far more ductile or distensible than the fascial coverings of some 
other parts of the body. The gland thus constructed is supplied 
with blood from the intercostals, the external mammary, and the in- 
ternal mammary arteries. The nerves of the breast are also derived 
from the intercostals and from branches that proceed from the axillary 
plexus. 

It has also an abundant supply of absorbents. The granules of 
the breast, or its acini, give out, each of them, a tube or lactiferous 
duct, which, uniting with others from the same bunch or packet of 
grains, at length form a lactiferous duct which proceeds towards the 
areola and nipple, so that each packet or nodule of acini sends its own 
excretory tube to the nipple, and has no connection with the circum- 
jacent nodule. In the same manner the lobuli of the placenta send, 
each of them, its vessels towards the cord without communicating 
with the adjacent lobules. 

The lactiferous ducts soon become, by the union of so many primi- 



596 MILK-FEVER. 

tire excretory tubes, quite large; and they become the larger, the 
nearer they approach the areola and nipple, in which they contract, 
and each tube sends its own duct to the nipple, on the extremity 
of which it opens, in order to pour its fluid into the infant's mouth, 
when it is draw T n forth by the suction of the child. 

It is stated by Haller, in his great work, and confirmed by other and 
later writers, that, in addition to the lactiferous tubes, which may be 
regarded as the efferent ducts of the acini and the packets, the galac- 
tophorous vessels are also composed of numerous excretory or efferent 
ducts w y hich take their origin from the adipose cells, and convey 
thence a material that helps to make up the constitution of the milk. 
I do not know that this question has been settled by any of the minute 
anatomists in America or elsewhere. 

The number of tubes opening on the extremity of the nipple amounts 
to fifteen or twenty, and each tube is lined, according to the opinion 
of Bichat, with a mucous membrane, since, he says, the orifices of 
all the glands are furnished with a mucous surface. 

Such being the construction of the mammary gland, it follows that 
its nervous and vascular apparatus, having extensive communication 
with the rest of the system, must endow it with the faculty of awaken- 
ing numerous and powerful sympathies in its diseased affections. 

The woman who approaches the term of her gestation feels the 
breasts grow quite heavy — they are rather firm in consistence, the 
areola becomes blacker and blacker, as she approaches her accouche- 
ment: after the child is born, she observes no change in them until 
the second, or more commonly the third day, so that, until forty-eight 
or seventy-two hours have elapsed, we have no reason to look for any 
fluxional movement in that direction. But about this time the breasts 
commence swelling, they ache, and suffer shooting pains throughout 
their substance : the swelling goes on until the skin of the mamma fairly 
shines with the tension ; blue veins, that are very broad, are seen creep- 
ing in every direction over the superficies of the hemisphere, and even 
the nipple partakes of the engorgement. The breast is now painful to 
the touch, and each one stands out so firmly and so hard from the 
thorax, that the woman is often obliged to lie upon the back for more 
than an entire day, being unable to bring her arms together on account 
of the pain the breasts would suffer in their approximation. 

In this state the breasts may be compared to two great phlegmons 
upon the most sensitive part of the body, and we need feel no sur- 
prise at finding such a state of the glands accompanied with fever, 
and even violent fever. Accordingly, it is very generally the fact, 



MILK-FEVER. 597 

that a woman does not get her milk without at the same time getting 
a fever with it, and this fever is called the milk- fever. 

I have not the least doubt that I have, on various occasions, observed 
the beginnings of a fever, which proved to be the milk-fever, and in 
which during many hours not the least appearance of engorgement, 
heat or painfulness of the breast was discoverable, signs which, 
however, afterwards manifested themselves, and which, together with 
the usual terminations of the fever in copious perspirations, after 
the usual course of nineteen or twenty hours, left no doubt upon my 
mind that the fever was milk-fever. 

In a good moiety of the cases, this, like other kinds of ephemeral 
fever, is ushered in with rigors, headache, and pains in the back and 
limbs. These pains are often intense, but the true type of the fever 
is, that it is an ephemera which declines soon, after a short and vio- 
lent hot stage, that gives place to a copious sour perspiration. 

If not before, then as soon as the milk-fever begins, the patient 
ought to take some aperient medicine, such as castor oil, salts, Seid- 
litz powders, or salts and magnesia: it is always cooling and calming 
for a feverish patient to have the bowels moved freely, and in this 
particular fever it is highly commendable to be watchful against any 
excess of violence in the febrile excitement. For my own part, when 
I find in a milk-fever that the pulses are strong and large and fre- 
quent, the calorific functions in high exercise, and the head and back 
and limbs aching, I rarely fail to let blood from the arm. This is the 
surest and most prompt method of relieving the present distress, and 
by far the most certain means of obviating the dangers which accom- 
pany all fevers in a newly-delivered woman. 

As I have said above, the nature of the fever is to be an ephemera, 
yet it but too often happens that this ephemera is converted into a 
long-continued fever or a remittent, during the course of which, 
various organs, and particularly the peritoneum and the womb, are 
excessively liable to be attacked. 

To take eight or ten ounces of blood, then, and to give a smart 
purge, is a very safe and commendable proceeding in all cases of 
milk-fever that are a little severe. 

I had, not long since, a young lady under my care in her first 
lying-in. The labor was very painful, and lasted about twenty-four 
hours. On the third day she had a rigor, heat, swelled and painful 
breasts, and a great quantity of milk. Instead of going off in eighteen 
hours, this fever lasted nine days, when there was a complete solu- 
tio morbi. I supposed her to be now well: but no — she was at- 



598 MILK-FEVER. 

tacked next day with all the symptoms of endocarditis, from which 
she barely escaped with her life. As the endocarditis went down, it 
was followed by a couple of very large and painful swellings, one 
over each sacro-iliac junction, both of which seemed to be doomed 
inevitably to suppuration. During the existence of these swellings, 
she had constant hectic ; but both of them were slowly and with diffi- 
culty discussed : after which she regained her health most perfectly, 
having lost her milk. For several days the friends of this lady de- 
spaired of her cure, and she did suffer the most distressing pains and 
weakness. Now I have related this case to show what may become 
of the most simple form of milk-fever, and the necessity of observing 
it, not so much on its own account, as on account of the conversions 
and depravations to which it is liable. 

I think that one of the fruits of the statistical methods which have 
become fashionable of late years, is the establishment of what, per- 
haps, might be properly called pathological Ontology. It seems to me 
that the tendency of modern writings is to make the Student and early 
practitioner believe that each disease is one and the same, saving the 
modifications that occur in its phases, from beginning to end. I pre- 
sume, however, there are few practitioners w T ho, from age and much 
clinical experience, have become familiar wdth the changes that take 
place in the diseased constitution, that are not aware of what has been 
called by a writer, the " conversion of disease." 

A disease may begin in the alimentary apparatus and end as a 
disease of the respiratory apparatus; a curable disease of the brain 
may, during its existence, introduce modification of the health of the 
respiratory organs, which being curable, nevertheless, during its ex- 
istence, brings about maladies affecting the kidneys, the spleen, the 
liver, or other noble parts of the body. It is difficult for me to con- 
ceive of a person dying of a single disease, for I firmly believe that 
life consists in the trinity of powers residing in the circulatory, oxy- 
genating and innervating organs; I am not surprised, therefore, to 
find a patient, who being seized with a rigor, the consequence of an 
overloaded or irritated mammary gland, is subsequently attacked with 
inflammation of the broad ligaments, uterine veins, or the peritoneum, 
in consequence of the increased simple momentum of the blood, and 
the modifications of the nervous force dependent upon the febrile con- 
dition. I need say nothing as to the changes in the crasis, or the 
mixt, of the blood itself, affected by the violent thrashing force of the 
ventricles and the impetuous rush of that fluid through the arteries 
and capillaries of the body. 



INFLAMMATION OF THE BREAST. 599 

When, therefore, I find a lying-in woman with a synochus fortis 
pulse, notwithstanding I regard a status of the mammary gland as 
the cause of the phenomena, I tremble lest the force of the circulation 
should overcome the feeble barriers which the physiological condition 
of the fatigued and exhausted child-bearing organs offer against its 
violence. 

I, therefore, make haste to reduce the violence of milk-fever within 
safe limits, by employing the only sure and the most effectual of all 
therapeutic resources against it, to wit, that of venesection. 

I deem it advisable to say here, that, whereas the practitioner 
occasionally meets with seasons in which the constitution of the air 
highly favors the occurrence of child-bed fevers, he ought, as soon as 
he discovers such a propensity among his lying-in patients, to put not 
only the nurses who may be under his guidance, but also some of the 
responsible members of the family, upon their guard, in order that 
the very earliest intimations may be given to him of the attack of 
milk-fever. This is rendered necessary by the circumstance that milk- 
fever begins with intense rigors, and even with shaking ague, in many- 
cases; and that it. ought always -to be regarded as uncertain for puer- 
peral women where the blow may fall whose signal is a chill. It may 
fall safely and harmless on the gland of the mamma, or it may descend 
w T ith irresistible and destructive violence on the veins of the womb or 
its muscular structure, or to light up a broad and raging flame of in- 
flammation in the whole peritoneal membrane. How needful is such 
a precaution, in view of the exigent demand for a bold, prompt and 
liberal use of the lancet. 

When the breast is filled to distension with milk, the whole organ 
becomes heated, and of an increased sensibility. This excitement of 
course extends to the areola and the nipple. This last-mentioned 
organ is also subject to be contused by the action of the child's gums, 
betwixt which it is pressed with considerable force : besides this, the 
suction power of the infant's mouth, equal to a weak cupping, attracts 
into its vessels a great quantity of blood, which, by frequent repetition 
of the suctions, establishes at last an engorgement, and even a positive 
inflammation of its skin and areolar tissue. The nipple, once in- 
flamed, is readily excoriated by the suction and friction to which it is 
exposed, and thus is established that painful affection called sore nip- 
ples. Sore nipples maybe an affection either of the cylindrical part of 
the nipple or of the extremity of the organ ; the former is of less evil 
consequence than the latter. When the mass of the nipple has once 
become inflamed, hard and highly sensitive, it is common to find a 



600 INFLAMMATION OF THE BREAST. 

quantity of exudation matter, like croup membrane, adhering to the 
very extremity of the mammilla; when this exudation matter falls off, 
the surface is left raw, having lost its epithelial covering. If the 
child be not frequently applied, and the gland be very productive, 
the heat, painfulness and tension of the whole breast are distressingly 
aggravated by the collection of milk within the galactophorous canals. 
There is no hope under these circumstances that the great hypere- 
mia and hyperneuria of the mammillary process shall become less ; the 
causes act and react mutually, and the inflammation, turning inwards 
upon the milk tubes of the nipple, spreads, by continuous and contigu- 
ous sympathy, into one or more of the large canals, which are already 
over-distended, and, therefore, in a morbid state. The foundation for 
mammary abscess is very commonly laid in this train. For the most 
part, the excoriation occurs near the base of the nipple, in a fold or 
wrinkle of the skin which half encircles the part, and which, when 
placed in the child's mouth, is to the most exquisite degree painful. 
Tears are seen to roll down the cheeks of the patient every time she 
takes her nursling to the breast; and she comes at last to lose her 
spirits, and to grow moping and melancholy, to such a degree as 
greatly to retard her convalescence, or even to cause the attack of a 
fever of a serious nature. 

There can be no surer proof of the difficulty of curing any disorder 
than that drawn from the vast variety of remedies for it. It is well 
known that the remedy for intermittent fever is the Peruvian bark, or 
its preparations — everybody is agreed on that point: so also mercury 
is a proper remedy for lues — which few persons doubt. But, as to 
sore nipples, the whole world seems to have been ransacked for cures, 
and in a thousand lying-in rooms we shall find a thousand different 
cures, which, after all, are not capable of curing the malady. For my 
own part I do not believe in the cucumber ointment so praised by 
Velpeau, nor the unguentum populeum, nor the lead-water, nor the 
castor oil, nor the borax and brandy of Sir Astley, nor the infusion of 
green tea, nor the slippery elm bark. I make it a point to examine 
the sore nipple for myself. If I find an excoriation or an ulcer seated 
upon a nipple actually turgid with inflammation, and highly sensible 
to the touch, I advise some blood to be drawn by a circle of leeches 
set on the white part of the breast just beyond the areola. This 
leeching, followed by an emollient poultice of flaxseed mixed with 
crumbs of bread and milk to cover the whole nipple and areola, is 
soon followed by a reduction of the inflammation. When that is sub- 
dued, the crack, fissure or ulcer begins to heal very kindly under the 



INFLAMMATION OF THE BREAST. 601 

gentle stimulation of a weak solution of nitrate of silver. After this, 
the cucumber ointment, or a true pommade made with scraped pippins 
stewed in prepared lard or any proper base of an ointment, causes 
the cure to be soon effected. As this ointment is a very useful one 
in many occasions of disorders of the breast, I will not refrain from 
giving the Student the following formula for its preparation, and though 
I am no great believer in the virtue of salves, I shall not blush for 
having descended to so small a particular as this. I beg leave to say 
that, as the ointment cools, it should be constantly stirred or moved 
with a wooden spatula, which serves to give it a granular character. 

B. — White wax, two ounces. 
Deer's suet, six ounces. 
Oil of almonds, two ounces. 
Scraped pippins, four ounces. 
Dried currants, two ounces. 
Alkanet, one drachm. 
Mix. — Melt in a water-bath, and simmer for a sufficient length of 
time ; strain the hot liquid, and beat it in a mortar or on a slab to 
make a proper ointment. 

In those cases w T here the pain is very great, a present means of 
relief or palliation is to be found in touching the sensitive part with 
lunar caustic, which, though it smarts for a few moments, is soon 
followed by a diminution of the sensibility and pain. Let the caustic 
touch only the excoriated part; if it act on the parts not already ex- 
coriated, abrasions of the sound epithelium follow, with a correspond- 
ing enlargement of the sore. 

In applying the nitrate of silver, one should use a very fine-pointed 
camel-hair pencil, which, being moistened with water, may be touched 
with a portion of solid nitrate, until the water in the brush shall have 
taken up a sufficient quantity of the salt ; with this delicate point, the 
cracks or fissures, being slightly stretched apart, may be accurately 
touched on the granulations, so as to avoid the risk of destroying by 
the caustic the tender margin of cicatrization whose white band 
girdles it ; to take a coarse piece of solid nitrate is to put off the cure 
for a whole day, which is a great evil. 

The late Dr. Physick, whom I consulted in regard to a most painful 
excoriated nipple, taught me that I should cure it as I would cure 
an incised wound or any ulcer — that is, by bringing the edges as 
nearly as possible into contact. A bit of fine ribbon, called taste by 
the shopkeepers, was thinly spread with adhesive plaster; and very 
narrow strips of the plaster, several inches in length, having been 



602 INFLAMMATION OF THE BREAST. 

prepared, were applied in a direction transverse to the fissure or crack 
so as completely to close the wound or ulcer; the strips were removed 
for the purpose of giving suck, and always replaced immediately after- 
wards. The method of the good surgeon was rapidly and completely 
successful, as I have found it to be on numerous other occasions since 
that time. 

During the process of cure of sore nipples, very great comfort is 
obtained by causing the child to suck through the artificial nipple 
made by covering a proper shield of pewter with the nipple of a heifer. 
Such artificial nipples are prepared in great perfection, and sold by 
the apothecaries in this city. They prevent the direct contact of the 
child's gums and tongue with the diseased organ, and thus allow 
the parts to heal with great celerity in some instances. It sometimes 
happens that the child refuses such a nipple, but in the great majority 
of cases the infant takes it well, and the pain and inflammation soon 
afterwards disappear. There is also a variety of shields or caps for 
covering the nipples, in order to prevent them from being pressed or 
rubbed by the dress of the patient. 

When the breasts are filled with milk, their lactiferous tubes are 
liable to over-distension, to such a degree as to excite in them an in- 
flammatory action. They are also, in this state, liable to injury from 
the pressure of a tight dress, or from the use of a dress so loose as to 
allow the heavy organ to be suspended by its own tissues, which is 
painful and irritating to the last degree ; or it is exceedingly liable to 
be injured by the mother lying upon it in her sleep, or by the child 
bruising it by bumping its head against it. Lastly, as I have already 
said, the irritation of a sore on the end of the nipple is readily propa- 
gated along the course of the milk-tubes into the substance of the 
breast, so as to produce there a more or less violent inflammation. 
Cold and damp air, to which the woman sometimes imprudently ex- 
poses the organ while in the act of suckling the child, especially if 
while in a state of perspiration, is a pretty frequent cause of the 
difficulty; and, indeed, there are to be met not a few females who 
possess what may with great propriety be called an irritable breast, 
and to such a degree that the slightest exciting cause, as cold, pres- 
sure, distension or the like, establishes the inflammatory action at once. 
Some people are so plagued with frequent attacks of milk-fever or 
weed, that they are compelled to wean the child in order to get rid of 
the milk and the irritability which it brings along with it. I know a 
lady who has had the breast so irritable, that whatever cause hap- 
pened to excite a too active movement of the blood in the vessels, 



WEED. 603 

would seem sufficient to establish so great an affluxion to the breast 
as to inflame it to her great distress, trouble and disappointment. 

The Student ought to be made to understand, that, after entering 
upon the practice of medicine, he will very often be called on to give 
his opinion for nursing women, whom he will find complaining of 
headache, pain in the back and limbs, with a very frequent, full and 
hard pulse; these symptoms having been ushered in with a chilly fit 
of one or two hours' duration. He will rarely fail, under such cir- 
cumstances, to make at once a correct diagnosis, if he ask the question, 
whether there is pain in one of the mammary glands ; and if answered 
in the negative, let him not give up the inquiry — but let the gland be 
pressed betwixt the thumb and fingers. If there is any soreness there, 
it will in this way be readily detected. A small lump is very likely 
to be found, as big as a nutmeg or larger, which alone is sufficient 
cause and explanation of so much constitutional disturbance. The 
inflammation and obstruction of a single galactophorous tube are suffi- 
cient to produce chill, fever, cephalalgia, and pains in the limbs, like 
those of break-bone fever. , 

Whenever the milk-fever, or the fever arising from an irritated state 
of a part of the mammary gland, is very great, the patient ought to 
be bled. Eight or twelve ounces will mostly be enough for one ope- 
ration: a smart purgative should be afterwards given; the patient 
directed to put a poultice of milk and bread upon the painful part of 
the breast, and to keep her bed. It would be most unfortunate for 
her to refrain from suckling the child, which ought to go to the breast 
whenever it is found to fill up with its milk. 

In the course of a few hours after the bleeding and the operation of 
the cathartic, fifty or sixty leeches should be applied near the painful 
part, unless the local disorder should by that time be greatly reduced 
in intensity. 

These leechings are highly useful, and ought to be repeated daily 
in those cases which seem not to require or admit of the employment 
of the lancet, but which at the same time demand the local abstraction 
of blood. In one patient here I had a large number of leeches applied 
to the breast: they were useful, but did not cure the pain and obstruc- 
tion. The leeching was repeated seven times before the inflammation 
gave way. In a subsequent confinement, they were applied nine 
times before they succeeded in relieving the distended, hardened and 
painful tissue of the breast. 

As I have already said, the mammary gland is suspended upon 
the skin in front of the thorax; whenever it becomes heavy from 



604 



WEED. 



engorgement or from obstruction of its milk tubes, it tends to fall 
downwards from its weight, and in doing so the natural relations of 
tension of its integral parts are disturbed, I might say destroyed. 
To explain myself fully, I will say that the gland is dragged, pulled 
by its weight, and that the nerves and blood-vessels of supply are 
put uneasily and even pathogenically to the strain, just as happens 
to the testis in a hernia humoralis. 

I should think no surgeon at the present day would treat a hernia 
humoralis without the aid of a suspensory bandage, and I am equally 
sure that no thoughtful practitioner would undertake to treat a violent 
case of mammary inflammation or mammary abscess without pro- 
viding some proper means of suspending the organ or of preventing 
its fall downwards; a fasciola or strophium of some sort should be 
resorted to in every such case, and I advise the Student to make 
use of a fasciola or strophium consisting of a strip of patent adhesive 
plaster, sixteen or eighteen inches long, and little more than an inch 
in width. Let one end of this adhesive strip be carried far back and 
high up under the axilla, and affixed to the skin there ; then let the 
breast be raised up by the hand to its normal position, and while so 
supported, let the plaster be brought round underneath the hemisphere 
and carried upwards until the end applies itself as high as the op- 
posite clavicle. One such strip will be in many cases found sufficient 
to cure even a violent inflammation of the mammary gland, just as 
a considerable orchitis is often cured by a suspensory bandage alone. 

I exhort the Student of medicine to make himself acquainted with 
the uses of the breast, to know T the nature and sources of its circu- 
lation, innervation and absorption, as well as its secreting office, in 
order to prepare himself to combat fully the ills that menace those 
persons who confide to his skill and conscientiousness the preservation 
of their health in the lying-in-room. It is difficult to form an opinion 
of the amount of poignant distress, depression of spirits and actual 
loss of health attendant upon some of the cases of mammary abscess, 
which from beginning to end occupy months; besides ruining the 
gland, to the great detriment of the patient in future confinements. 
A mammary abscess is a very serious matter, demanding a con- 
scientious regard to the fulfilment of all the duties incumbent on the 
practitioner in the case, yet often treated with neglect and indifference. 

Lying-in women are managed by their monthly nurses or friends, 
and it is very difficult for the physician to make either the patient or her 
attendant understand the true wants of the case. I am very sure that 
a great proportion of the mammary abscesses that I have met with in 



MAMMARY ABSCESS. 605 

my life have been the results of over-distension of the milk-tubes; nor 
can I well understand that one or a dozen galactophorous tubes, as 
large as swan quills, should be filled to their utmost capacity for seve- 
ral hours with milk, without determining in their mucous and fibrous 
structures such a hypereemic and hyperneuric condition as to result 
in the establishment of inflammation of those tissues. But such in- 
flammation passes through such tissues to the gangue of cellular 
tela by which they are invested ; heat, swelling, pain, and redness of 
the parts follow upon such an engorgement, commonly in the course of 
a few minutes, or certainly in the course of a very few hours: a con- 
dition likely to be aggravated by the increased distension which a 
failure to draw off the milk, whether from ignorance or timidity, in- 
variably produces. 

I believe the Student cannot possibly become too vigilant and anx- 
ious to explore, and therefore to obviate, the mischievous tendency of 
the engorgement now spoken of; he should give such directions as to 
emptying the breast, either by the aid of the nipple tube, the breast- 
pump, or other method, as may save his patient from the certainty of 
developing mammary abscess. 

A mammary abscess for a lying-in woman is a great misfortune; it 
almost deserves to be called a catastrophe; and for a woman, indeed, 
who has a bad constitution, or who is affected with a strumous habit, 
or is at all prone to tuberculosis, a mammary abscess is a circum- 
stance replete with alarm and danger. If the suppuration be very deep- 
seated, it sometimes happens that many days, or even weeks, are 
passed before the matter of the abscess makes its way to the surface ; 
in the meantime, a constant fever, exhausting perspirations, and a 
state of the constitution that can only be truly characterized as hec- 
tical, attends the painful and reluctant progress of the suppuration 
outwards. But, suppuration, when it takes place, often attacks 
several of the different loculi in which the independent packets and 
bundles of the milk-tubes, and granules of the gland, exist; so that 
a -woman is affected with an abscess which is really multilocular in 
its nature, and. which, when evacuated, allows the cavity to be con- 
verted into winding and many-celled sinuses, difficult to cure and 
often lasting for weeks and months. I need not allude to the ex- 
haustion, the pain, the hectical fever, and the wasting discharges of 
suppuration. I repeat that it is almost a catastrophe for a lying-in 
woman to be attacked with a mammary abscess, and particularly if 
regard be paid to the great domestic vexations often produced by it. 
The young child is often the victim of such an accident, and the 



606 MAMMARY ABSCESS. 

whole household is sometimes kept in a state of disquietude for an 
entire year, by the dissatisfaction engendered from the necessity of 
frequently changing the wet-nurse, who is brought in to relieve the 
woman herself, or to preserve the child from the dangerous conse- 
quences connected with artificial alimentation. 

An abscess is a circumscribed cavity containing pus; one of the 
causes of the pain is the tension, and it is desirable that the character of 
the abscess should be abolished, as soon as it may be done conforma- 
bly with the interests of the patient. As soon as the abscess is opened 
by the bistoury, or by the natural process of absorption, it ceases to 
be an abscess and becomes a deep-seated ulcer; the tension and pres- 
sure are, therefore, either greatly lessened or wholly removed. In the 
treatment of mammary abscess, however, it appears to me not desira- 
ble, in general, to draw off the matter from a great depth below the 
tissues, because in doing so, the fistula, through which the matter es- 
capes, and which is made by the lancet, is almost sure to become 
sinuous, and to convert the abscess into a fistulous ulcer. Hence, I 
should deem it advisable, in the conduct of such cases, to wait rather 
longer than in some other abscesses for the rising of the pus to a point 
near enough to the surface to obviate this risk. 

During the progress of the suppuration, great comfort is obtained, 
first, from supporting the gland by means of an adhesive fasciola, or 
strophium ; and, secondly, from dressing it with emollient poultices. 
I think that poultices are more useful if they contain the petals of 
chamomile, or hops, or crushed onions; for the use of these agents, as 
it appears to me, serves to prevent the formation of those eczematous 
blotches and patches which are apt to follow the simple poultice of 
bread and milk, of flaxseed, of slippery-elm, or other emollients. I 
do not think that anything can be more suitable for the treatment of 
this part of the case than the poultice composed of equal parts of 
slippery-elm flour, flaxseed meal, or crumbs of bread, and chamomile 
petals. As soon as the breast is opened, whether spontaneously or by 
the surgeon, poultices may be abandoned, and a practice introduced 
of compressing the breast against the arch of the ribs by long narrow 
strips of adhesive plaster, which cross it in various directions, take firm 
hold on the thorax to compress it, and hold it still. The effect of the 
compression is to counteract the development force of the still re- 
maining uncured inflammation of the tissues. 

There is no antiphlogistic that can compare with the power of 
mechanical compression for cases in which it is possible to adjust it, 
and it is possible to adjust it for the female breast. Every day dur- 



MAMMARY ABSCESS. 607 

ing the treatment, and indeed several times a day, a delicate cereole, 
made of cere-cloth, should be introduced into the opening and con- 
ducted to the bottom of the tube or sac. If the cereole be not dis- 
proportionately large, it gives no pain, and its withdrawal is followed 
by gushes of pus or sanies, whose detention in the bottom of the tube 
or sac reconverts the malady, restoring it to the nature of an abscess, 
for an abscess is a circumscribed cavity filled with pus. 

It appears to me that, managed in this way, there will be found 
few samples of gathered breast obstinately to resist the treatment. 

In many instances where the suppuration makes its way to the 
surface, within or near to the margin of the areola, milk is found to 
escape along with the pus, and a troublesome milk-fistula is generated 
by it; sometimes these fistulas of milk continue to flow for a great 
many weeks, accompanied with a very small quantity of purulent 
matter, and a portion of sero-pus or sanies. To shut up the orifice 
with adhesive plaster is to re-form the abscess, since it reproduces a 
circumscribed cavity, and the abscess opens again and again — a 
cause of great vexation. I have found them, I think always, yield 
upon the daily introduction of a delicate cereole, made of cere-cloth, 
which should be carried to the bottom of the cavity, and withdrawn 
from time to time to allow of the escape of the contained fluids, but 
to be replaced immediately afterwards. It generally happens very 
soon that the cereole goes less and less deeply into the tube which, 
filling up with granulations from the bottom, at length precludes the 
possibility as well as the necessity of its introduction — for the fistula 
is cured. 

In the winter of 1840, I attended a lady confined with her first 
child. She was so extremely modest, that, several days after the 
birth of the infant, being seized with inflammation of part of the 
gland of the left breast, she would not allow the nurse to inform me 
of the accident, lest I should wish to examine the part. In this 
way, she continued to bear the pain for several days, until it became 
so great that my attention was called to it. I advised the use of 
leeches. Compliance with this order was deferred for two or three 
days, and when at last yielded it was too late to do any good. The 
breast suppurated near the posterior surface, almost down on the 
fascia; the pus was long making its way to the surface, which it did 
at length, and was evacuated by an incision. The case altogether 
was rendered a most embarrassing one by the timidity and nervous- 
ness of the patient, who became so very ill as to excite in me the 
most painful solicitude. I was for many days anxious on account of 



608 MAMMARY ABSCESS. 

a very wearying short cough, for which I could discover no explana- 
tion upon a most careful auscultation of the thorax. The pulse was 
always above one hundred and ten. Upon going to see her one 
morning, I found her with the most singular respiration and pulse 
that I had ever seen, connected with any exterior disorder of the 
breast. Her pulse was not less than one hundred and sixty beats a 
minute, and the respiration was more than one hundred times a min- 
ute. Her hands were covered with moisture, and from her emacia- 
tion I felt the greatest inquietude upon finding so strange a state of 
her circulation and respiration, which, she told me, had come on shortly 
before, having been of the same character once or twice some hours 
previously to my visit. 

After looking upon this strange scene for a minute or two, and 
after repeating the auscultation, I begged permission to examine the 
breast, which had been more painful. I found a new abscess point- 
ing up under the skin. As soon as I opened it, and with a bistoury 
cut up a bridge of skin which strongly bound two other orifices, her 
strange respiration gave instantly place to a very calm and deliberate 
one, while her pulse also recovered a far more natural rate. This 
lady having lost all her milk, took in a wet nurse, and after some time 
recovered a very perfect health, after the most distressing and pro* 
tracted illness brought on by a simple, but neglected, inflammation of 
the lactiferous gland. 

In the second volume of Bright' s Medical Reports, p. 459, there is 
related a case of what he calls hysteric dyspnoea. 

"I was passing," says he, "through the wards of George's Hos- 
pital one day during last winter, when one of the surgeons requested 
me to look at a female patient who had a formidable disease of the 
mamma. She had been seized with alarming dyspnoea: her respira- 
tion was performed with most unusual effort, but it was not so much 
hurried as laborious; and she complained of a constriction across the 
chest which was altogether unconquerable. Pulse very quick. It 
had been believed by some that she suffered an attack of pneumonia; 
but there was no cough, and the breathing was rather with effort than 
with pain or difficulty. Her feet were quite cold, her pulse weak. 
She was in a state w T hich might have resulted from sudden effusion 
into the chest, or the bursting of an aneurism. This was hysteria, 
and assafetida was its cure." 

I wish the Student to compare Bright's case with mine given above, 
the slowness of the respiration in his with the frightful acceleration 
in mine, and all co-existent with formidable disease of the mamma, 



THE BREAST. 609 

and then observe that my patient was instantly and completely re- 
lieved by the bistoury, while Bright's was cured by assafcetida. I 
should think he would come to the conclusion that neither of the cases 
was really to be arranged among the hysterical disorders, but were 
the results of irritation of a gland, having so large a supply of nerves 
from within the thorax itself. 

It is highly advisable to wean the child, when sufficient time has 
been allowed to ascertain the probable long duration and great seve- 
rity of a mammary abscess. This ought not to be done too early, 
because the suction of the breast by the child is a great and curative 
resource in the management of the disorder; when the inflammation 
confines itself to only a part of the breast, the other portions of the 
gland continue to furnish a good abundance of milk, and that milk 
ought to be regularly taken away, lest its accumulation should add to 
the difficulty already too great within the inflamed packets, or even 
invite the inflammation into the still healthy structures. 

For counter-sunk nipple and inverted nipple, I refer the Student to 
my letter on the Breast in my work on Females and their Diseases, p. 
643. To the same letter I beg leave to direct his attention for a fuller 
statement of this subject, than I find occasion to present in the present 
volume. 

I shall close this article, by advising every Student who intends to 
practise midwifery, to dissect the breast for himself, after having most 
carefully studied " The Anatomy of the Breast, by Sir Astley Paston 
Cooper. London, 1840, 4to. with a vol. of Plates." This work is 
really a legacy to those whom in his dedication he calls "My dear 
Brethren." It is prepared with an elegance and liberality and pro- 
fuseness of illustration worthy of that great surgeon. The republica- 
tion of it in the United States, in a style fully equal to that of the 
London edition, would be a very great benefit not only to the profes- 
sion, but to thousands of suffering females, whose disorders of the 
breast would be more fully understood, as soon as that work should 
find its way, as assuredly it would, through the country. 



39 



PART IV. 

THE HISTORY AND DISEASES OF THE YOUNG CHILD. 



CHAPTER XXIII. 

The child in utero, as has already been stated, requires for its com- 
plete development a lapse of nine months, or two hundred and eighty- 
days, less or more. It becomes viable at seven months. 

Some children have lived, that have been born much earlier than 
this ; yet it is true to say that viability is attained at the seventh month. 

The viability of the foetus depends upon the evolution and perfec- 
tion of its organs to such an extent as to enable it to live a respira- 
tory life. This it could not do until its lungs should be sufficiently 
evolved to enable the air-cells to receive the atmospheric air, while 
they should become fitted also to make the transfer of oxygen to the 
blood and of carbon to the expired air. If a child should be expelled 
while its air-cells were still undeveloped, it would necessarily perish 
immediately from asphyxia; new-born children expelled before their 
time die, not because they have a complete but because they have a 
partial atelectasis pulmonum. 

The heart of a child, in the earlier of its embryonal periods, is a 
straight tube ; it soon becomes tortuous, and afterwards makes two 
cavities, which are one auricle and one ventricle. The progress of 
the uterine life brings the foetus daily nearer and nearer to the condi- 
tion of the breathing mammal; but it does not attain this condition, 
as a general rule, until the seventh month of gestation. If the child 
should be driven into the w r orld before the completion of the organi- 
zation of its heart, it could not be deemed viable or liveable, because 
it could not successfully carry on the work of oxygenating its brain 
and nervous mass. 

The septum ventriculorum of the foetus in utero is early completed: 
if the septum auricularum should be also completed before the period 



VIABILITY. 611 

of its birth, the child would necessarily be born dead, because there 
is no other route by which the oxygenated blood of its placenta could 
be submitted to the action of the systemic ventricle, save that in which 
it traverses the right auricle, passing through the foramen ovale to the 
systemic ventricle, and that which it performs when driven by the 
right ventricle into its aorta through its ductus arteriosus. The red- 
blood of its ductus arteriosus enters the aorta below the giving off of 
the carotids and subclavians: that blood can by no means reach the 
brain, but goes into the tissues below, where it gives up its oxygen 
or returns to the placenta to take an additional charge of it: therefore 
none of the oxygeniferous blood of the child can reach the brain, 
save that which comes into its systemic ventricle through the foramen 
ovale and the left auricle. A child, therefore, whose foramen ovale 
should be completely closed — to suppose the case — would necessarily 
perish in utero with asphyxia, for asphyxia is black blood in the brain; 
nothing else is asphyxia. 

The neonatus, therefore, is necessarily born with an open foramen 
ovale; but the foramen ovale is covered by a valve on the left surface 
of the septum: this valve serves after its birth as an operculum or 
lid to shut the passage. It is probable that the first inspiration of 
atmospheric air, coinciding with the descent of the diaphragm and the 
expansion of the thorax in every direction, serves to carry off to the 
lungs through the pulmonary artery, a great efflux of blood, which, 
antecedent to that first act of respiration, chiefly but not wholly flowed 
off through the ductus arteriosus. The constantly augmenting facili- 
ties of this pulmonary circulation soon set aside any further necessity 
for the transitive agent — the ductus arteriosus, whose deserted channel 
soon becomes a ligamentous band. 

The increased amount of blood thus determined to the lungs, must 
have the effect of throwing a greatly augmented quantity of fluid 
upon the right auricle and ventricle ; not to say that the right side of 
the heart carries on a greater circulation after birth than before birth; 
but the right ventricle cannot but carry on a much greater amount 
now, because it carries on the whole, whereas, before birth it carried 
on only a moiety. 

The escape of the blood from the right ventricle into the pulmonary 
artery is probably effected with a facility greater than was that of its 
propulsion into the aorta through the ductus arteriosus; and I can 
imagine that now, the pressure of the two symmetrical parts of the heart 
being equalized, the valve of Botali instead of floating upwards into the 
left auricle, is by this equalization of the pressure, shut down as the 



612 N ON- VIABILITY. 

operculum of the foramen ovale ; so that, although the child is neces- 
sarily born with an open foramen ovale, the equalization of force in 
the two ventricles serves to close it immediately after the first act of 
aspiration. The Student need, therefore, suffer no disquieting doubts 
or uncertainty in regard to the openness of the foramen ovale in the 
healthy neonatus at term. 

In the non- viable child, previous to the seventh month, the valve 
of Botali is incomplete and has not a perfect operculum; it cannot 
thoroughly cover the orifice of the foramen ovale. If the child, there- 
fore, be born without a complete valve it will probably die from as- 
phyxia, from the mixture of its black and red currents in the systemic 
ventricle; a child, therefore, whose heart is incomplete is non-viable. 

A child is rendered non-viable in consequence of many faults of 
development. The astomatous child is non-viable, as is that in which 
the oesophagus has failed in part of its development, rendering the 
cavity of the stomach inaccessible to aliment. The anencephalous 
child is non-viable, since important parts of its organization are wholly 
wanting; the acephalous foetus dies of course. The child is non- 
viable in which ectopy of important organs, as for example ectopy of 
the liver and the whole alimentary canal in the root of the umbilical 
cord, exists; for the cord being deciduous must fall off in the course 
of a few days, leaving the vital organs exposed to inevitable ruin. 
The child is non-viable in whom large portions of the rectum fail to 
be developed, although a few T examples are met with in which the 
surgeon, by a dexterous operation, has saved the life of the child la- 
boring under imperforate rectum; probably those that have been thus 
saved, have failed to produce merely a short tractus of that intestine. 

Many children perish in the womb from disorders affecting impor- 
tant parts. Doubtless in the early stages of embryonal life, very 
slight derangements in the structure of the omphalo-mesenteric 
vessels, or of the duct of the umbilical vesicle, might and do deter- 
mine the death of the new being. Children also perish in the w T omb 
from diseases affecting parts within the cranium, for the child lives by 
its nervous mass as truly as the breathing animal does. Diseases of 
the kidney and liver and alimentary apparatus, prove the not unfre- 
quent causes of the death of the child in the womb. 

Various affections of the mother produce the death of the child ; 
passions of the mind and physical distempers, to which she is subject, 
bring it into danger, or destroy its tender existence. Various diseases 
affecting its umbilical cord, modifications of its placenta, whether as 
to insufficient magnitude of that organ, or modifications induced by 



STILL-BORN. 613 

the deposit of calcareous carbonates upon the uterine surface of the 
placenta, or the establishment within it of the disease, called hydatid 
degeneration of the organ, or partial detachment of the placenta, 
serve to destroy the young child before it is born. 

The child, when it is driven into the world, is sometimes found 
unable at once to establish its respiratory life ; it lies still and pale, being 
perfectly motionless; there is little tension of its muscles; if handled 
it appears to be flaccid, or, to use a common phrase, limber, like a 
person who has fainted. If the cord be taken between the finger and 
thumb, nigh to the navel, the Student will be able to judge whether 
or no the heart is beating. If the heart is beating, the pulsations 
w T ill be felt by the finger and thumb by compressing the cord, in 
w r hich are the two umbilical arteries; if the pulsations are vigorous, 
and repeated at the rate of about one hundred and forty pulses per 
minute, no alarm need be felt as to the security of the infant. In a 
few T moments the diaphragm will receive its nerve-stream; it will 
descend, compelling the air to enter the lungs; the oxygen of the 
atmospheric air, combining with the blood of the pulmonary circula- 
tion, will hasten to the systemic ventricle which, injecting it into the 
brain, extricates there an explosion of vital force, which irradiates with 
instant life every nerve fibril in the constitution. This new and pow- 
erful infusion of vital force is made manifest by struggles, by outcries, 
by rapid coloration of the surface, and by all the signs that indicate 
an established respiratory existence. 

As soon as the child is found fully to have established its respiration, 
steps should be taken to sever it and remove it from the mother's 
couch. As before directed, a ligature should be put upon the umbili- 
cal cord, at the distance of an inch and a half or tw T o inches from the 
navel. Tying of the cord is not an indifferent matter, and it is ne- 
cessary to examine the ligature that may be presented for the purpose 
before employing it; it should be strongly jerked between the two 
hands, in order to test its strength. It ought not to be less than ten 
or twelve inches in length; a portion of ligature four or five inches 
long cannot be firmly held, for it becomes slippery in the moistened 
hands. If it be not of sufficient strength it may, in tying the first or 
second knot, give way, and allow the two hands to separate with 
violence, which exposes the accoucheur to the risk of tearing the cord 
out at its root. When the cord is passed around the umbilicus it 
should not be tied without taking the greatest care to avoid this sudden 
separation of the hands that are employed to tie it, upon the possible 
breaking of the ligature. The cord should be ten or twelve inches 



614 SEVERING THE CORD. 

long, as I have said, so that, being held in the hands and the knot 
arranged, it can be fastened by separating the radial edges of the 
hands, rolling them both outwards in supination, without a direct 
steady pull. I never think to tie an umbilical cord in any other man- 
ner than this, and more particularly as my early experience placed 
me repeatedly in danger of destroying the child, by suddenly jerking 
its navel string, from the breaking of improper ligatures placed in my 
hands. 

In applying the ligature to the umbilical cord, one may be em- 
ployed or two. If it should be a twin pregnancy, there surely ought 
to be two ligatures, lest, if there be a common placenta, the second 
child should suffer a dangerous loss of blood, from the untied end of 
the cord. In those cases in which the placenta is known to be de- 
tached and pushed into the os uteri, it is better to have only one liga- 
ture, for, in that case, the blood of the placenta is discharged in 
considerable quantities from the cut extremity of the cord, thus serving 
to diminish the magnitude of the placental mass very considerably, 
and enabling the woman to thrust it forth with less effort and less pain 
than would be otherwise required. 

On the other hand, if before proceeding to the severance of the 
child, the uterus is found to be still very large, in consequence of con- 
taining the placenta in its cavity, it is better to apply a second liga- 
ture ; by doing this the Student would restrain the evacuation of the 
placental blood, and thereby keep the organ fuller, more plump and 
solid, which would enable the uterus more readily to slip it off from 
the utero-placental superficies than it could do if the placenta, by the 
evacuation of all its blood, should become flaccid, like a wet, soft 
sponge. 

The child, being removed, should be washed and afterwards dressed. 
It should be washed in tepid water at all seasons of the year. The body 
of the new-born child is usually covered with a flaky, unctuous matter, 
or induitus that is insoluble in water, and is not acted on by means of 
soap; it readily incorporates, however, with oil or lard or the yelks of 
eggs. One or two yelks of eggs, beaten up and rubbed over the 
whole surface of the child, suffice to make an emulsion of the white 
induitus of the child, which is afterwards readily washed away by 
means of soap and water ; or the whole child should be carefully and 
thoroughly anointed with a handful of lard, which also incorporates 
readily with the viscous matter in question, and which is readily 
washed off afterwards by means of soap. If the attending nurse is 
inexperienced, the Student should direct her to use, not a piece of 



DRESSING THE NAVEL. 615 

linen or muslin, but a portion of soft flannel as the wash-rag for the 
purpose of cleansing the child's body; either linen or muslin slides 
over the surface and fails to pick up every portion of the induitus, 
whereas every particle of it is taken up by means of a wash-rag 
made of the bit of flannel. 

In cold weather the child should be washed in a warm room, and 
sufficiently near to the fire ; but its surface burns readily ; let the Stu- 
dent take heed, therefore, that its body is not exposed to be blistered, 
as I have seen them blistered, by being held too near an open fire or 
grate. 

As soon as the child is thoroughly washed, a piece of linen, four 
inches wide and eight inches long, should be doubled to make a square 
disc ; in the centre of this disc a slit should be made with a pair of 
scissors — it is best not to cut a round hole in it. Through this slit 
let the remnant of the navel string be passed, so as to let the double 
disc of linen lie upon the belly of the infant ; the cord should be laid 
down flat upon this disc pointing upwards towards the scrobicle, the 
linen should then be turned up so as to cover it, the right side of the 
piece should be turned over the cord towards the left, and the left 
side of the piece should be turned over covering the right, which will 
effectually envelope the navel string, which is all the dressing it can 
require. The object of this dressing is to receive the discharges 
which exude from the navel string, and to prevent the cord from ad- 
hering to the child's dress, to which, without some such precaution, 
it would soon become glued and thus be liable to be torn off earlier 
than the period at which the natural process would otherwise detach 
it ; there is no other use in dressing the navel string of which I am 
aware. 

As soon as the cord is thus dressed, the belly-band, which is 
usually made of a strip of flannel four or five inches in width, should 
be put over it, and the end, carried around the body, may be pinned 
either at the back of the child or at the sides. After this the child 
should have a shirt large enough to come down nearly to the hips ; 
if it is too long, it w T ill be constantly wetted with its urinary dis- 
charges. Next comes the petticoat, which is usually, in this country, 
made of flannel, and which has or has not, according to the taste of the 
mother, a shoulder strap, but which always has a proper waistband. 
Some persons do not employ the petticoat, but a good many women 
still use here the barracoat from the Portuguese, barra, an ell of cloth. 
It is a yard of flannel, more or less, of which one end is fastened 
around the waist, and the other brought up and pinned in front, so as 



616 DRESS. 

effectually to cover up the lower extremities of the child— a conve- 
nient and facile mode of dressing it in cold weather. 

The last covering is the frock. I should hardly deem it neces- 
sary to mention it here, were it not, in the first place, that I am 
writing for Students, who ought not to go to the lying-in room without 
being provided with some information upon particulars, which, though 
they be of minor importance, are not without their influence upon the 
comfort and safety of his patient and upon his own success and repu- 
tation. But, more than this, I mention it, because I desire here to 
enter my solemn protest against the folly, the stupidity, and I might 
say the iniquity of the fashion which induces so many persons, pos- 
sessing in other respects good sense and good education, to dress their 
new-born children less wisely than an Osage Indian mother, or the 
most savage Esquimaux. A child that is born does not surely belong 
to its parents until it has attained its sixth year ; it seems to me that 
such a child is but a loan, on condition of becoming property, provided 
it be wisely and safely conducted up to the sixth year of its age, for 
one-half of the annual product of child-birth perishes in six years. 
It cannot be that this amazing mortality is an inevitable concomitant 
of the state of existence, but it must be a result of ignorance and 
carelessness as to the hygienical conduct of the neonatus and the young 
child. It is true that a multitude of children are brought into the world 
endowed with such a feebleness of constitution, or such hereditary 
depravation of it, as to render protracted existence and maturity 
impossible, but the population abstracts would find an immense aug- 
mentation were a sound discretion to preside over the hygienical 
management of newly-born children. Now in the United States, from 
Carolina to Maine, and from the Atlantic board to the western limits 
of Missouri, Iowa, and Wisconsin, little children are dressed in frocks 
without sleeves, or having only pretended sieeves, which are really 
nothing more than shoulder-straps and while the backs and bo- 
soms expose nearly the whole of the thorax. There would be no 
objection to such habits for children born between the 10th of July 
and the autumnal equinox, it would even be advisable so to dress the 
summer children, in a climate notorious for its intense light and heat ; 
but to dress children in the same manner, whether born in July or 
February, is an imprudence which no power but that of Fashion could 
compel sensible women to commit ; but Fashion has a power that 
transcends the dictates of wisdom and of common sense. 

I wish in this volume that the Student should know that I have in- 
variably, for a long series of years, combatted, as far as in me laid, 



DRESS. 617 

this vicious custom ; I have found a few sensible mothers who would 
listen to and obey my injunctions, but I have found a vast number of 
children to suffer, and a multitude to perish, from their disregard of 
the dictates of common sense. I beg the Student, therefore, to take 
this matter into his serious consideration and to satisfy his own judg- 
ment upon the question, whether a child is safe, the whole of whose 
tender extremities is exposed to temperatures approaching to and 
sometimes lower than the freezing point. 

The arms of a child are supplied with blood mainly by the delicate 
tube of the humeral artery. Much of the blood returns in the super- 
ficial veins, and great masses of it, either upon the skin or in the 
fingers, to resist the constringing effects of cold require a power 
of the circulation, probably amounting to what might almost be 
called pathological reaction. The superficies of the body covering 
the lungs, is also often chilled, for the infant, " mewling and puking in 
the nurse's arms," always has the whole front of its chest wet with the 
excretions of its mouth ; such a condition can scarcely fail to expose 
it to attacks of pulmonary catarrh, of tracheal and bronchial inflam- 
mations, and coryza. 

One of the causes most destructive to health is cold, especially 
damp cold, and the new-born child ought to be carefully protected 
against it by dresses, covering its chest up to the throat, and its arms, 
down to the wrists, and its legs and feet. 

I believe that in Europe, where the people by long residence have 
been compelled to learn the nature of their climate, one would scarcely 
meet with a child, from the royal infant to that of the beggar, that 
would not be found better protected against weatherly influences than 
the children of the United States mothers. 

The pretext for this improvident exposure of the neonatus is, that 
it should be early hardened; but I submit to the intelligent Student 
the question, whether the surest way to harden a child is not that way 
which shall conduct it through the first six years of its existence with- 
out fever, inflammation, or other disease. If a child be properly co- 
vered up and daily exposed to the sunlight in the open air, it will 
have the best chance of acquiring what is called a hardened consti- 
tution ; there is little hope that a delicate child, otherwise cared for, 
shall pass to the end of the first month of its life without some degree 
of coryza, some pulmonary rhonchus, or some reactive effort of its 
vascular constitution, struggling against the constringing effects of 
cold damp, from which it cannot be protected except in overheated 
apartments, which themselves are almost as much to be deprecated. 



618 



FOOD. 



If a child, protected like a sailor on an Arctic voyage, or like the 
rudest workman, should be daily sent sub dio, to breathe the stimu- 
lating and exhilarating air of the streets or country, and its diet should 
be properly regulated, there are few diseases to which it would be 
liable, save those essential maladies which, to use the language of 
Willis, — " homini omni, soli et semel contigit offici." I mean measles, 
small-pox, scarlet fever, whooping-cough, etc., for I am very sure 
that the catarrhs, the pseudo-membranous croups, the bowel complaints, 
and many even of the cases of tubercular meningitis, are the results 
of management, scarcely wiser than that bestowed upon the child of 
the Ottawa, or the Shoshonee. 

With these observations on the dress of the child, I shall dismiss 
the subject, after proffering one more remark; it is, that the people of 
the United States seem all hurried onward by the universally pervad- 
ing desire to do what is here called go-ahead; they are notoriously 
regardless of the care of their health, and this is attributable, perhaps, 
to the state of the people, who have but yesterday, as it were, con- 
quered their lands from the swamps and the forest, and have been too 
busy with progress to attend to the minor concerns of the savoir vivre. 
I hope that no distant generation will be left to discover some portion 
of the agreeable to mix with the overflowing cup of the useful in the 
United States. In that case the mortality reports will be less redund- 
ant with the infant proportion, and the whole female American race 
will present a spectacle very different from that which we now behold, 
since it is rare to meet with an American wife, the mother of three 
children, not already broken and ruined in health, by her servitude to 
the laws of fashion and the raging spirit of progress. 

Let us now turn our attention to the alimentation of the child. It 
might be enough to say, for the information of any man of sense, that this 
is a generical process, for the child was made for the breast and the 
breast was made for the child, and nothing else, in this line, w T as made 
for either; therefore, when the child is fed otherwise than at the breast, 
it is fed by a suceedaneum; every succedaneum is, by comparison, 
infinitely inferior in value and properness to the generic food which 
the Author of Nature supplied for it, and so constructed its organs and 
parts as to fit them to receive it and to be developed by it. I shall not 
take the trouble, in this volume, to repeat the analyses and the obser- 
vations upon milk which I have already printed in another work, nor 
indeed does it require any argument to show that, inasmuch as the 
proportion of oil, casein, albumen and water in the milk of the differ- 
ent mammiferous creatures varies according to their genus, so the young 



FOOD. 619 

of each genus is adapted to the reception of the sort of aliment de- 
voted to its generical nature. 

It is true that a young child who has lost its mother must be fed, 
and it is better for it to be fed with cow's milk or goat's milk than not 
at all ; but I hold it to be a sacred duty for all those persons whose 
circumstances admit of it, to provide the new-born child witk the 
milk of a human nurse, and not to expose it to the hazards — I should 
say the dangerous risks — of distressing illness and impending death, 
that threaten the great majority of those children that are brought up 
on the spoon or biberon. 

The neonatus comes into the w T orld full of instinctive desires, it 
will take food soon after its birth, and will satisfy its instinctive crav- 
ings to absolute satiety. But I beg the Student to remark, that while 
the Divine Author of Nature has ordained that children shall be born, 
he has also ordained that the plenary abundance of their food shall not, 
as a general rule, be provided for them until the third day after birth. 
It is not necessary, therefore, to feed the child as soon as it is washed 
and dressed ; I look upon it as a direct flying in the face of Providence, 
as acting in direct contravention to the law of nature, which is but 
the command of God, to fill the stomach of the new-born infant with 
mixtures of saccharine matter, of gruel, or of the milk of quadrupeds: 
surely He who made it knows better its true wants than those who, 
doubting His wisdom and foresight, make haste to test its digestive 
powers by these detestable mixtures, instead of waiting the fullness of 
His own time. 

I have warned the Student, however, that hereafter he will encounter 
much trouble and vexation in consequence of the early and improper 
feeding of the infants under his care, and I exhort him by careful 
consideration to inform his mind as to the medical duty in such 
cases. He will never err, he will never go astray as a physician, who 
ascertains clearly the physiological laws of the function or functions 
placed under his surveillance, as he who in his hygienical ordinances 
is the best expositor of nature's laws, will be the safest and most 
successful physician; and it is certain that no human sagacity or skill 
can ever equal the perfection of those operations that are instituted 
and effected in accordance with the generical nature of the subject of 
them. 

It is a mistake, and it is a grave mistake, to suppose that the neo- 
natus is in danger of starvation that is kept until the third day by the 
supply furnished it from the mother's breast, for there is always, after 
the birth of the child, to be found some small quantity of mammary 



620 FOOD. 

secretion, which, though it be not properly deserving to be called 
milk, yet it is possessed in a measure of the properties of that fluid. 

The earliest secretions of the milk gland are loaded with a vast 
abundance of colostrum grains, which are to be seen thickly strewn 
over the field of the microscope, mixed with vesicles and oil globules 
floating in the serum lactis. Probably the imbibition of this colos- 
trum by the child has some economical relation to its conservation. 
The colostrum disappears in the course of a fortnight or at most three 
weeks after the child's birth; I cannot imagine that it is a mere ex- 
cremental matter, for the breast is not an excrementitious it is a re- 
crementitious organ, and all that it produces is designed for the advan- 
tage of the new-born child. 

With these views I am quite clear in advising the Student to direct 
his patient to take the nursling to the breast at the earliest convenient 
moment. I have many times seen a child drawing vigorously at the 
breast within a quarter of an hour after its birth, and I believe to take 
the child to the breast is the most natural thing for the mother to do. 
To illustrate this opinion, let me invite the Student to consider the 
circumstances that might have attended the apparition of the first- 
born of mankind. The common mother of mankind had perceived 
the strange sensations and modifications of her form, dependent upon 
an advanced stage of her first gestation. She resided, perhaps, in 
some warm sunny valley of the Caucasus, bounded by an amphithe- 
atre of lofty mountains, and enriched with a varied landscape, 
tinted with every hue and form of tree and flower and grassy mead. 
A transparent fountain arose, perhaps, near the bower, in which Adam 
had left her sleeping at the uprising of the morning. He may 
have climbed some lofty, distant cliff to gather for his bride its 
Alpine blossoms, or return, loaded with fruits for the object of his 
tender care. In the meantime she is seized with the pangs of the 
first human travail — the terrible fulfillment of the curse on her early 
disobedience ; alone, unaided, in a purely natural state, with that in- 
herent health and strength which we may conceive of as appertain- 
ing to a creature which had issued perfect from the hands of her 
maker, she advances through the unknown conflict, and at the mo- 
ment of its consummation, becomes insensible from the keenness of 
her anguish. In a few moments she is recalled to her senses by 
the voice of the new-born child ; and, raising her languid head 
and inclining her bending body feebly supported upon the elbow, 
she perceives the helpless child of her bosom lying upon the grassy 
floor of the bower near her. It is not necessary to paint, indeed, 



FOOD. 621 

it is impossible to imagine, the intenseness of the parental emo- 
tions which must have now agitated her bosom; these, instinct alone, 
would prompt her to put forth her hands and lift her first-born from the 
earth on which it laid weltering. She would take it up in her hands, 
her forearms were fashioned that they might be its cradle, its face would 
fall against her bosom, and it is probable that but a few moments 
elapsed after the birth of the first-born, until his mother experienced 
the sensations which only a mother can know, who pours the rich 
nutritious stream of life out of her own breast for the sustentation and 
comfort of her new-born offspring. It is perfectly natural, I repeat, 
that a mother should take the child to the breast at the earliest pos- 
sible period after its birth. Every human direction and counsel in 
contravention of this most evident law of nature, must be erroneous, 
save when it is founded upon views relative to the actual state of 
the mother or child, as setting aside, for the moment, the operation of 
those natural laws. 

Some information should be given to the inexperienced mother or 
nurse, in regard to the alimentation of the neonatus. I believe that 
pure instinct is more unerring than reason, and a better guide in all 
those cases in which instinct is designed to preside. I therefore look 
upon it as a tyrannical thing on the part of any physician to prescribe 
precise intervals between the applications of the child to the breast. 
I have no idea that any physician can be competent to decide upon 
the degree of activity of the digestive powers of any specified neona- 
tus. The principles of conduct here, are principles to be derived 
from a knowledge of the wants of the child ; a child may want the 
breast again in two hours, or it may not want it again in six hours. 
It is therefore preposterous on the part of the physician to say, as I 
have heard him say, that the child must be applied to the breast every 
three hours, or every four hours, according to his unerring wisdom. 
I advise the Student to direct the child to be fed when it is hungry, 
and allow it to be governed, as to the quantity it takes, by its instinct, 
which is superior to his reason. 

It is probable that the child within the month, w r hose stomach can 
scarcely be supposed to hold, when perfectly satiated, more than three 
or four fluidounces of milk, will be able to digest and discharge the 
major part of this quantity into the duodenum, in the course of some 
three hours after its assumption, and it is probable that the feeling of 
hunger will begin to return long before the organ becomes com- 
pletely empty. There are but few new-born infants that are incapable 
of rejecting a part of the ingested milk; the stomach in this w T ay re- 



622 food. 

lieves itself of any excess, which the appetite might induce it to swal- 
low. I have no doubt that a considerable portion of the ingested milk 
passes as milk and not as chyme through the pylorus. These con- 
siderations, together with observation of the facts, have induced me, 
in general, to say that the child might be applied to the breast about 
once in three hours, but I am far from prescribing three hour intervals 
as an absolute rule of conduct, and I have no objection to see the 
child again applied to the breast within two hours after having 
thoroughly satiated its desire for food, for I repeat, I rely upon its 
instinct, which was provided for it before the invention of Physic and 
Surgery. 

The dental formula of animals is the index to their nature, espe- 
cially to the nature of their alimentation. This mere fact is sufficient 
to make it apparent that the child should be fed upon fluid aliment, 
up to the time at least of the establishment of its dental formula; and 
nothing could be more stupid than the conduct of those that feed 
young. babies with bits of fat ham, minced chicken, and other arti- 
cles of food for which the child does not become fitted until the period 
when nature announces it to be so, by the establishment of an ap- 
paratus of mastication. 

As a general rule, the child ought to be nursed at the breast until it 
is twelve months old ; if the twelve months should happen to elapse 
about the beginning of June, it ought to be kept at the breast until 
the autumnal equinox, since experience declares that in the U. S. very 
few children can be severed just at the outburstingof the summer heats, 
without becoming subject to some degree of digestive derangement, 
which, when once begun, is not readily removed where the child is 
nourished artificially, but w^hich either does not attack, or is readily 
overcome, if the supply be of the kind of food which is natural to it. 

As to the nursing of the child, notwithstanding I deem it a sacred 
duty on the part of the parent to fulfil this obligation, yet it is ques- 
tionable whether the obligation is not really set aside where the pro- 
vocation thereto arises from a dangerous condition of the maternal 
health. If a man marry a wife having a hereditary claim and expect- 
ation to perish with pulmonary consumption, it would be better, both 
for her and the infant, to dispense with the giving of suck. It is 
probable that the infant has already caught a touch of the taint or the 
diathesis, almost in the act of conception, and if not then, within the 
course of the uterine gestation. The sooner all influences of the 
mother's life over it shall pass away, the greater is the hope of its 
escaping the terrible fate before it; and on her part, it may be said 



food. 623 

that the rudest and strongest health is oftentimes much diminished 
and shaken by twelve months of lactation, but, for a person having 
in the lungs the invisible seeds of a tuberculosis, to subject such a 
one to the exhausting processes of the long lactation, is to nurture and 
call them into a fatal activity. 

I do not mean, in these expositions, to recommend that the lying-in 
woman should at once begin to throw back upon her constitution the 
fluxional movement towards the mammary glands, which can only be 
normally counteracted by the physiological action of the gland. Her 
own safety exigently demands that she should favor its fluxional move- 
ment for a few weeks, but after four or six weeks she ought to let her 
milk slowly dry away, and provide for her child a wet-nurse of un- 
questionable qualities. 

I can conceive that, by proceeding in this manner, a family line 
might cast out of its stock even the tuberculous diathesis, in the course 
of a few generations; but it is melancholy to contemplate the misery 
which is in store for those, who, preferring the enjoyment of their 
natural and praiseworthy sentiments, turn a deaf ear to the warning 
voice of experience and prudence. 

Counsel, however, is to be given by the physician who is to be all 
things to all sorts of people; and it must be, that he shall have to 
counsel those whose circumstances forbid them to defray the extra 
expense of w r et-nursing. Under such circumstances the child must 
be fed ; milk is its food, and the best succedaneum for its mother's 
milk is the milk of the cow — indeed, there is none other to be had 
in the United States; it would be in vain in this country to recom- 
mend either the use of asses or of goat's milk, which, in various coun- 
tries in Europe, is abundantly provided for those who may find occa- 
sion to employ it. 

With regard to the artificial alimentation of a child, the Student 
should reflect a moment, and he will come to the conclusion that the 
act of digestion is much assisted by the admixture with the food that 
is ingested, of a due proportion of saliva. The saliva, though not 
so essential in the digestive evolution as the liquor gastricus, is a 
very indispensable agent in the act. A child that draws its milk 
from its mother's breast by the suction power of its mouth, may be 
almost said to masticate it, and in doing so occasions a stream of 
saliva to pass into the mouth, which it swallows along with its milk. 
The proper excitant of the salivary glands is firstly, perhaps, the 
presence of alimentary matters in the mouth, and secondly, still more 
powerfully, the motion of the tongue and cheeks and gums, in eating. 



624 THE UMBILICUS. 

Now, a child that is fed from a spoon may be almost said to hare the 
food poured down its throat without swallowing it, and the same is true 
of the infant that takes its aliment from the edge of a bowl or cup. 
It is far more convenient and proper, in all cases of artificial aliment- 
ation, to simulate as closely as possible, the functions, and I believe 
that the child will digest its gill or half pint of food more safely and 
successfully, if it be taken through the biberon than if taken out of 
a spoon or cup. Let the Student give ample attention to these con- 
siderations, and judge for himself whether the remarks be well founded 
or not, and thereupon base his professional counsel. 

Without going into an examination of the different kinds of food, 
I prefer to request the attention of the Student to the opinions which 
I have expressed upon this subject, in my work upon Diseases of 
Children. 

Of the Navel. — The navel being dressed in a manner heretofore 
described, it is usually left thereafter to the care of the monthly nurse 
or attendant, and the physician is rarely called upon to interfere, ex- 
cept when it becomes the seat of some diseased action. 

The remainder of the umbilical cord, left after the severance of the 
child, soon begins to dry; the water of the Whartonian jelly contained 
in it, escapes through the inorganic pores or crevices in the amniotic 
coat; the vein usually contains a small coagulum of blood, and the arte- 
ries become collapsed and entirely desiccated. In the course of from 
four to seven days, the cord has become so dry and thin as to resemble 
a piece of transparent, yellow horn; the absorbents at the level of the 
demarkation early commence to cast off the slough, by establishing 
a crack or fissure all around its root, the fissure growing deeper and 
broader from day to day, allowing the desiccated vestige to fall away, 
leaving a small spot of raw surface, often not bigger than the head of 
a pin, for most of the wound becomes incarned or cicatrized as the 
process goes on. 

While the child is in the womb, and even at the moment of its 
birth, the navel protrudes, often to the length of half an inch; but the 
two arteries, whose cut ends are attached near the surface of the new 
formed cicatrix, act as cut arteries always do, by retracting and serving 
to draw the navel inwards and downwards in the direction of the 
urachus. The remainder of the vein, which becomes a cord passing 
alono- the ed^e of the falciform ligament of the liver, is also, but in a 
less degree, retracted. These vessels serve in this way to draw the 
navel inwards and to make the dimple of the umbilicus ; but the deepest 



THE MECONIUM. 625 

pit of the dimple will look downwards towards the bladder, for the 
retractility of the arteries is the greatest. When the retraction thus 
effected is perfect, the tissues are drawn strongly inwards towards 
the inner aspect of the belly, and the vacuity in the linea alba, con- 
stituting the umbilical ring, becomes perfectly closed; but if this 
retraction be incomplete, then a plug of tissues contained within the 
circle of the umbilical ring prevents its absolute closure, and leaves 
the child liable to be affected with exomphalos or pouting of the navel. 
It is clear that in order to aid this retraction and complete it, a 
proper compress should be adjusted over the umbilicus and retained 
by the belly-band, whose use ought to be continued as long as its 
use is indicated. If the child is quiet, little given to crying and 
straining with tenesmus, and if the dimple of its navel be perfectly 
w r ell formed, the belly-band may be left off at the end of a month, 
but the least disposition to protrusion, or a wintery season, furnish oc- 
casion for its longer continuance. 

Of the Meconium. The meconium of the child is a dark, viscous 
green, diffluent matter which is contained in its colon and rectum at 
the period of its birth. 

The quantity is sometimes very great, and its first alvine discharges 
consist wholly of this material. Three or four of the first evacuations 
serve in general to carry it all off; occasionally it is so adhesive as 
not to quit the surfaces of the bowels; perhaps it is lodged in the cells 
of the colon, so that the bright bile-tinted stool of such a child, seen 
upon its napkin, induces a belief that the meconium is all purged off, 
whereas subsequent dejections show that no inconsiderable quantities 
have been detained in the intestine. 

When the meconium comes off freely, and seems to be entirely 
discharged, giving place to excretions of a healthy hue and consist- 
ence, no medical precautions can be deemed necessary; but if the 
child is uneasy, crying, fretful, affected with griping pains, which are 
betrayed by its voice and by the frequent flexion and extension of its 
lower extremities, with an appearance of passionate impatience, and 
especially if some portions of the meconium seem to linger upon the 
napkin one after another, we should have reason to suppose that the sur- 
faces are still vexed and irritated by this excreted matter, w T hich ought 
to be removed by small portions of castor oil or some other convenient 
aperient. 

Children that feed many times a day will generally be found to 
require several alvine dejections per diem. A child that satisfies its 
40 



626 ALVINE EVACUATIONS. 

instinctive desire for food, generally does so by filling the stomach 
until it is quite distended, and it will often happen that some portions 
of the ingested milk will pass off through the pylorus into the intestinal 
canal too early to have been subjected to the influence of the gastric 
liquor. Such portions of milk will, therefore, appear upon the nap- 
kins in broken, fine coagula of a white color. 

Most children, after filing the stomach to distension, enjoy the 
happy faculty of regurgitating the excess, so that the stomach soon 
becomes relieved of its over-fullness, retaining all that it has received, 
and subjecting it perfectly to the gastric digestion. A child that in 
this manner rejects the superfluity and completes the digestion of 
what remains, will have small residue of its ingestions and, therefore, 
will have fewer alvine discharges, which shall be smaller in quantity 
than those of the child a portion of whose undigested milk passes into 
the duodenum and jejunum. 

Without being able to speak positively from careful observation, I 
venture to state that the neonatus in perfect health has three or four 
changes of its napkin daily, and I conceive that this is not too great a 
number; at the same time I presume that a child might be very well, 
having only one dejection per day, provided it is known to have the 
faculty of regurgitating the superfluous ingestion, and provided also it 
has the appearance of enjoying a complete health. 

I beg to inform the Student that he will meet with a good many 
children which shall have eight, ten, sixteen, twenty dejections per 
diem, and that he will often be called upon by anxious parents to 
prescribe for such seeming diarrhoea. The case to which I allude is 
not a diarrhoea, it is a case in which a child, nourished at a free and 
abundant breast, fills its stomach again and again with a gastromor- 
phous clot of milk, a major part of which being comminuted by the 
contractions of the organ, is driven off through the pylorus, because 
the child has not the power to get rid of it by regurgitation. 

When I am called upon to give counsel in such cases, I do not 
always take it for granted that the child is sick because the nurse or 
mother tells me it is so, nor do I admit that it has a disease because it 
has twenty stools per day. Under such circumstances I have often 
said let it alone, do not interfere with the case at all, except by re- 
gulating the amount of its food ; do not give it such frequent oppor- 
tunities to suck, and decide carefully when it shall have what is 
necessary for it and then put it away. If you give medicine to stop 
its diarrhoea — which is not diarrhcea, but repletion — you will make 
the child sick, for if the child continues to live in the same way, so 



ALVINE EVACUATIONS. 627 

as to require twenty napkins per day, and you prevent the action of 
its bowels, by means of some astringent or narcotic medicines, you 
will make it really ill — it is a case for hygiene not for therapia. 

I do not fear that I shall mislead the Student by the above observa- 
tions, because, if he be a man of sense, he will judge for himself, 
and not from me ; he will inquire what is the nature of these dejec- 
tions, which are accused of being diarrhoea, and if he should find that 
they are such as I have above described, he will perhaps remember 
my words, and act in accordance with the indications that I have 
pointed out. If the stools consists of masses of slime — if they are 
altogether bilious, if they give evidence of an excessive acid saburra, 
then he will inquire into the particular wants of the case, and pre- 
scribe accordingly. 

The mucous, the bilious, or the acid saburra, may require only a 
teaspoonful of castor oil, a small quantity of rhubarb, a portion of 
magnesia, a half grain of calomel, or calomel with chalk; or perhaps 
he will be enabled to fulfil the therapeutical indication by prescribing 
a portion of lime water and milk, or a little soda or potash mixed 
with water alone, or mixed in infusion of chamomile or some other 
bitter or aromatic garden herb. Possibly he may find the fault to con- 
sist in ahyperneuric condition of the peristaltic fibres either of the small 
or of the large intestine, and he will correct such an hyperneuria by 
means of an anodyne draught. An anodyne draught for the new-born 
infant should consist of half a drop of laudanum in a teaspoonful of 
water ; to give half a drop of laudanum let him direct the nurse to put 
two teaspoonfuls of water into a cup and add one drop of laudanum 
thereto, which, being perfectly mixed and compounded, permits him 
to give in one teaspoonful of the mixture, just half a drop — the other 
should be thrown away. 

Sometimes the new-born child, instead of being troubled with too 
many dejections, is affected with costiveness. This costiveness is 
overcome either by a suppository of molasses candy, of a bit of 
castile soap, of a camel's hair pencil dipped in castor oil, and thrust 
just within the grasp of the sphincter muscle. It may be remedied 
by an enema of tepid water, or water quickened with a modicum of 
salt, or molasses or castor oil ; or the child may take a teaspoonful of 
a weak infusion of rhubarb, or a little magnesia, or a little rhubarb 
toasted in a saucer until it is slightly brown, or, what is better than 
all, a pinch of pure precipitated sulphur mixed in water, sweetened 
with honey, or honey of roses. Small portions of sulphur mixed with 
honey water, appear to me to operate upon the neonatus more kindly 



628 ALVLN'E EVACUATIONS. 

than any other therapeutic agent, in this peculiar sense, and the use 
of it, continued for a few days, often serves to remove an habitual 
disposition to costiveness. The Student should judge, however, in 
the eases commited to his care, as to the cause of the constipation. 
He knows, or he ought to know, that the bile furnished by the liver 
is the natural eccoprotic, and that if that bile should be in just quan- 
tity and of due quality, it should take the place of all rhubarb, senna 
and purgative drug. 

If upon inquiry into this case then he discovers a deficiency in the 
abundance of the bile, or, such modifications of its tint and qualities 
as seem to call for his therapeutical intervention, let him judge as to 
the precise nature of that intervention. Let him ask himself what 
is the source of the blood, which gives rise to the secretion of bile, or 
from which the bile is secerned, in the eliminating apparatus of it — in 
the liver. He will see that the whole of this blood came from the 
aorta, through its cceliac and its two mesenteric arteries; that the chief 
torrent of it, after being passed through the capillary circulation of 
the intestinal tube, hath been collected again by the radicles of the 
great portal vein, which lets it into the liver to be distributed through 
the hepatic branches of the vena porta? to the capillary tufts in the 
acini, whence it is carried off again by the nascent radicles of the 
hepatic veins, which are to discharge it into the cava — and so his 
question is answered, for he will scarcely believe that the hepatic 
artery is the secreting tube, but only the nutritious artery of the liver. 
When, then, he finds a child disordered as to the action of its bowels 
and liver, I hope that he will cast his eyes upon this great system of 
what the ancients called the mesaraic circulation, so that, inspecting 
the whole field of it, he may discern in what point of it the pathoge- 
nic principle resides. 

I should think that he could not look upon a hyperemic condition 
of the capillary system of any large portions of the alimentary tube 
as matters of indifference ; for the performance of the secerning func- 
tions of the liver and the retardation in the movements of the great 
external portal system or of the great interior portal system, cannot but 
be regarded by him as proving sufficient causes of those modifications 
of the functions of the liver which he desires to cure. Under these 
views it will not always be for him inevitable to administer mercurial 
remedies for slight derangements of the bile. He will provoke the 
peristaltic fibre to greater or renewed action, with a view to remove 
those embarrassments of the portal or mesaraic circulation which he 
shall accuse of the hepatic difficulty, and he shall find there a tea- 



THE GUM. 629 

spoonful of castor oil, or a pinch of rhubarb, or a modicum of magne- 
sia, or an innocent dose of precipitated sulphur, quite as effectual 
and abundantly more safe than the vaunted power of the mercurial 
dose in these affections. 

It appears to me that in the United States, there is an indissoluble 
alliance between the word liver and the word calomel, and that the 
idea of the alterative power of calomel springs spontaneously at the 
least suggestion of an hepatic or bilious derangement. I do not deny 
that calomel is a purgative, or that it produces the most deadly nausea 
when taken into the stomach, nor that it may therefore, upon proper 
occasions, be rightfully administered, even to young children; but a 
conspectus of the circulation and of the innervation in those parts 
which stand before the gate of the liver and which serve, as it were, 
as the propyla, admitting the torrents of circulation into it, out of 
which the bile is to be taken by it, ought clearly to point to states of 
those parts, as the mesentery, the mesocolon and the alimentary canal 
itself, as the often seats of those pathogenical influences which are 
discoverable only in modifying the bile. 

I beg the Student to get his neonatus through the month without 
mercury, if possible; since, though I deem mercury an admissible 
remedy, I consider it a most desirable thing for the young child to 
avoid its too dangerous and powerful influences — influences capable 
of making such a profound impression upon the constitution as shall 
be felt in long after years. For my own part, notwithstanding I have 
long been laboriously engaged in practice of my art, I feel very con- 
fident that I do not employ one hundred and fifty grains of calomel 
in the course of twelve months ; and that I find my patients not the 
worse off on that account, while I myself am preserved from an in- 
tolerable anxiety which its administration always excites in my mind. 

Of the Gum. — Children coming into the world — issuing from the 
soft and unctuous waters by which they have been surrounded — are 
washed clean and exposed to the stimulating effects of the atmospheric 
air, and are, besides, covered with clothes, all of which serve to irri- 
tate the tender and sensitive outer covering of the body, the derm ; 
moreover, the first copious indraughts of atmospheric air, changing the 
blood and converting it into tenfold more oxygeniferous streams, must 
have the effect almost of an intoxicating inhalation of nitrous oxide 
upon the child. The corpus mucosum of the skin becomes instantly 
reddened, and, in many children, so red as to present the appearance 
of engorgement or inflammation; and there are not a few of them, 



630 THE GUM. 

indeed, in whom this first burst of dermal circulation and hyperemia 
is so considerable as to be followed, in the course of a few davs, by 
desquamation, like that which succeeds to an attack of measles or 
scarlatina. We should not be surprised, therefore, to observe slight 
inflammations and eruptions of the superficial tissues; there are few 
children, indeed, who fail, in the first three or five days after their 
birth, to be attacked with a slight papular eruption which is called 
red gum, — a case in which a central papule is environed by a red 
aureole. It requires no particular treatment, since, like a vaccination 
it tends to cure itself; common custom and usage, however, prescribe 
the administration of weak aromatic infusions, which are supposed 
to possess a diaphoretic quality. Infusions of catmint, infusion of 
fennel, or anise, infusion of saffron, etc. etc., are commonly resorted 
to, and as they do not much harm it is not always, perhaps, the pro- 
vince of the physician to object to their exhibition. 

This red gum, or strophulus intertinctus, differs from the other sort, 
strophulus albidus, which exhibits a larger papule, more nearly re- 
sembling the blister of varicella, though much smaller than the vari- 
cella. It is not surrounded by a red aureole like the strophulus inter- 
tinctus. 

In children affected with either form of these eruptions, it is highly 
important that the skin should be frequently powdered with some 
proper fecula, and there is none preferable to that of ordinary arrow- 
root. The application of the fecula, under such circumstances, ap- 
pears to me to possess a remarkable power to allay the hyperemic and 
hyperneuric condition resulting in this form of eruption. 

Sore Mouth or Aphtha. — In the course of a few days after the 
birth of the child, it is common to find it a little more sleepy than 
ordinary, and to hear the nurses say, "It is sleeping for the sore 
mouth," and soon after, upon examining the interior of the lips, the 
gums and the tongue, they are found to be overspread with very 
minute white flakes, that look like small curds of milk. These are 
aphthae, or the thrush, or the child's sore mouth. The white deposit 
consists of a small quantity of excretion, albuminous, or, possibly, 
the fibrine of the blood, which is held in contact with the surfaces 
from which it exudes by a delicate film of epithelium, so that with the 
finger covered by a bit of rag, the white speck cannot be wiped away. 

In a short time, — that is, in the course of a day or two, — the pel- 
licle of epithelium gives way and the crust falls off, leaving sometimes 
a minute sore, and sometimes a renewed surface of epithelium from 
which the crust has fallen away. 



THE GUM. 631 

Of course this malady is the result of inflammation of the corpus 
mucosum of the interior of the mouth and lips, and it is, to all intents 
and purposes a true stomatitis-mouth-inflammation. In nine cases 
out of ten it cures itself, and it is, probably, in its nature, very like 
the strophulus intertinctus, or strophulus albidus, of which I have just 
spoken, which are affections of the mucous body of the derm, whereas 
this is an affection of the mucous body of the mucous membrane. 

It is usual to accuse the child as laboring under an acid saburra, 
and to furnish it, in consequence of that accusation, with a dose of 
physic, which for the most part it does not really deserve. But, inas- 
much as this mild stomatitis may rise to a considerable height, becom- 
ing in fact, a general and extensive inflammation of the tissues within 
the mouth, extending backwards into the fauces, and from the isthmus 
faucium into the throat, it is worthy of attention on such occasions, 
and should be treated in conformity with its nature. 

The custom among physicians and nurses in this part of the coun- 
try, is to attack the local malady by means of portions of borax and 
powdered sugar, of which a pinch is frequently to be put upon the 
tongue of the child, and it is supposed to have sovereign power as a 
remedy for this malady. There is little objection to the use of bi- 
borate of soda, and it answers a good purpose, being a substitute for 
severer and useless remedies; now and then, when the stomatitis 
rises to a great and dangerous height, it is useful to wash the mouth 
of the child with a mixture of lime water and fine Peruvian bark in 
powder, or to touch the irritated surfaces with a camel's hair pencil, 
dipped in a weak solution of nitrate of silver, of a strength ranging 
from one grain to two or three grains to the ounce of distilled water ; 
or a solution of sulphate of copper in combination with sulphate of 
quinia — two grains of the former and half-a-dozen of the latter in 
an ounce of w r ater, furnishes a mixture w T hich may be efficaciously 
applied by delicate contacts of the camel's hair pencil to the affected 
parts. If fever arise, or saburra or disorder connected therewith, let 
the Student bethink himself of the efficacy of his doses of calomel or 
magnesia, or aperative medicine of whatever kind. 

There is another kind of sore mouth which looks like this, and 
which is called muguet, and which is, I think, not so often met with 
in this country, as by some European practitioners. It is supposed 
to be a vegetable substance attaching itself to the interior of the 
mouth, and sporiferous in its nature, so as to be capable of greatly ex- 
tending itself when once planted there. It differs from aphthae or 
thrush by being uncovered, or having no investment of the stomatic 



632 JAUNDICE. 

epithelium. I am not familiar with it, and refer the Student to the 
authorities for further information. 

Icterus. — The neonat is very liable, in the course of a few days 
after his birth, to be affected with a signal yellowness of the whole 
skin and eyes, and to have his urine so stained with bile as to impress 
its color upon the napkins when dried from the urinary discharges. 

The icterus of the young child doubtless depends upon the regur- 
gitation of bile from the pori biliarii into the returning branches of the 
hepatic vessels, whereby the whole mass of the blood becomes stained 
with its yellow coloring material, which begins to appear first upon 
the colorless adnata, and next upon the whole dermal surface. Such 
a state of the skin does not imply absolutely a disease of the liver 
itself, since there are certain irritations affecting the duodenum, pro- 
ducing some degree of engorgement round about the ductus communis 
choledochus, and passing up along that tube, which might w T ell suf- 
fice to detain the secreted bile in the pori bilarii, and cause its regur- 
gitation in the manner above indicated. A dose of purgative medicine, 
freeing the stomach and duodenum and jejunum of a saburra, and 
relieving them thereby of a troublesome hyperemia, seems to me likely 
to set the gates of the bile wide open, so that, the regurgitation no 
longer being affected, the constitution soon eliminates the coloring 
matter of the bile from the blood, and the skin recovers its healthful 
hue and tint again. 

My clinical experience must have furnished me with numerous 
examples of these early hepatic derangements, as they are supposed to 
be, but it has left with me no painful impression of the dangerousness 
or the troublesomeness of the affection, which is transitory, disap- 
pearing in the course of a very few days. 

In those cases in which the inspection of the dejections shows that 
the bile escapes freely through the ductus communis into the duode- 
num, I am willing to wait for the result of such outflowing of the 
liquid, and for the return of the liver to its normal functional rate. 
Whenever, on the contrary, I discover whitish or clay-colored stools, 
or stools tinted faintly with a whitish-yellow bile, I am willing to ad- 
minister to my patient some doses consisting of the sixth part of a 
grain of calomel, repeated three or four times a day, and followed by 
a convenient quantity of castor oil or magnesia, or other approved 
aperient. 

Coryza. — Many young children suffer severely, soon after birth, 



CORYZA OR SNUFFLES. 633 

from attacks of coryza, commonly, by the nurses and old women 
called snuffles, and when the attacks are severe, morbid snuffles. 
Some children, indeed, appear to me to have come into the world 
giving evidences, with the very first acts of respiration, of the 
presence of this malady. I do not mean to say that they have coryza 
before they are born ; but rather that they are born with certain tend- 
encies which allow coryza to declare itself immediately after birth. 

Coryza or snuffles is a state of the mucous membrane of the nostrils 
and air-passages of the head in general, occasioning a great abund- 
ance of mucus to be excreted from them ; which, filling up the air 
passages and obstructing them, causes the child to breathe with diffi- 
culty, making a rattling or snuffling noise with every respiratory 
movement. 

Many of the cases, being very slight and going off after a few 
days, scarcely serve to attract the attention of the physician, and the 
wise women content themselves with applying the usual remedy, 
which consists, in this country at least, in the application of a little 
grease or tallow to the bridge of the nose. While it is perfectly true 
that coryza is in many cases a matter apparently of small moment, 
yet it is true that the Student, when he observes its existence in the 
little nursling, ought not to pass it by idly and without notice, for it 
is capable of producing the greatest annoyance in the lying-in room 
by interrupting the sleep of the baby, and thereby interfering with 
the repose of its parent, a circumstance always to be deprecated. 
But more than this, coryza may kill the child outright — a thing to be 
deplored in itself considered, and perhaps still more to be deplored 
on account of its possible influence on the health of the mother, who, 
in the early days of her lying-in, is easily moved by slight pathogeni- 
cal causes, which, when they but begin to operate, may have results 
the most disastrous. 

Let the Student, therefore, not idly regard a case of coryza in the 
neonatus, if he would extend his watchful care both over it and its 
hypersesthetic parent. An accouchee is not like anybody else, and 
things may kill her, which, under other circumstances, might pass by 
her as the idle wind. 

I wish the Student to understand that the new-born child has no 
reason, but only instinct ; that it is a purely instinctive creature, and 
implicitly obeys the provocations of its instinctive nature. It has an in- 
stinct to breathe, for which purpose it is supplied with two respiratory 
stigmata, to wit, its nostrils. It has another aperture, its mouth, which 
its instinct teaches it to use only as an agent of its alimentation, not 



634 CORYZA OR SNUFFLES. 

as an agent of its respiration. I wish the Student to understand 
that if he will stop the nostrils of a new-born child with two plugs 
of cotton or lint, so that no air can enter into those respiratory- 
stigmata, the infant will surely die within from one to three days, 
because, its instinct teaches it to breathe through its respiratory- 
passages and not through its mouth ; and because the subject of the 
experiment will persistently close its mouth or its isthmus faucium, 
and perish under vain attempts to continue its respiration through the 
closed up nostrils. 

When children die from coryza, as they not unfrequently do, they 
die in the manner just pointed out, and I adjure the Student who 
shall read this passage, to give his careful and candid attention to 
the doctrines set forth in it, and, looking upon the child that is seri- 
ously ill with coryza, see how, after making repeated attempts to aspire 
air through the nostrils, it suddenly starts forward, throwing out its 
hands with an appearance of agonized distress, and then, opening its 
mouth widely, suddenly makes a full and complete aspiration of air, 
which, dispelling for a moment the sense of suffocation, permits again 
the renewal of its vain attempts to breathe through the natural open- 
ings. If it had reason to guide it, as a man has, it might breathe with 
perfect facility throughout the most dreadful attack of coryza, even 
coryza maligna; but it has only instinct for its guide, and that in- 
stinct teaches it to breathe through the natural openings. 

I will take this occasion to remark that the loss of life from coryza is 
to be observed sometimes in children many months old, and that a child 
even over two years of age may be lost in this way, as I have learned 
by disastrous clinical experience, and if the Student who reads these 
passages should find any hesitancy in his mind to admit the truth of 
my explanation, I believe that all doubt would vanish from him if 
he would please to make the following experiment. Let him con- 
press the alse nasi together with his thumb and finger, and then make 
half a dozen consecutive attempts to breathe, keeping his mouth shut 
at the same time ; he will find that the effort to send down the dia- 
phragm and expand the thorax will produce within the whole chest a 
deep feeling of distress, amounting almost to pain. But let him re- 
peat the attempts five or six times consecutively; and then, while 
making the last attempts, suddenly open the mouth and permit the air 
to rush in a torrent into the air passages, he will have the sensations 
which I attribute to the young infant when, after its repeated attempts 
to breathe through the nostril, it starts forward, throwing its hands 
wildly abroad and filling its lungs with air through the opened mouth. 



CORYZA OR SNUFFLES. 635 

If the Student, after experiencing these sensations, will reflect upon 
the effect of such experiments, repeated through two or three consecu- 
tive days, by a tender infant just born into the world, he will agree 
with me, that stopping of the nasal passages is the thing greatly to 
be deprecated. I do not mean him to understand that in ordinary 
cases of coryza the child takes no air through its respiratory stigmata, 
for it does get that small portion on which it subsists in that way, up 
to the period, at least, in which the apertures, having become totally 
obstructed, compel it at last to make the sudden and convulsive aspi- 
rations through the mouth which I have attempted to describe. But 
the difficult and interrupted aspiration of air through nostrils only 
partially obstructed, is sufficient to diminish the amount of oxygen 
breathed upon the blood, and the torpid and imperfect innervation, pro- 
duced by the imperfectly oxygenized blood in the vessels of the brain, 
is followed by various derangements in the action of the organs whose 
force depends upon the regular supply of the vis nervosa. 

A young child, then, laboring under a considerable coryza, will 
have carboniferous blood in the systemic circulation; it will be pale, 
languid and unhappy, and is always exposed in consequence to 
attacks of pulmonary or cerebral or abdominal disorder. I look upon a 
child, whose nostrils are half stopped up whether by mucus, or by 
submucous infiltration, as in a state analogous to that of an infant 
laboring under a moderate degree of pseudo-membranous laryngitis; 
for the one or the other equally prevents the aeration of the blood 
with its necessary amount of oxygen, and all the consequences of 
such a state result. 

I ask the Student whether the constitutional disturbance arising 
from such a degree of disorder as exists in the Schneiderian surface 
in a case of coryza could possibly be so disastrous, were it not for 
the accidental interruption occasioned by it to the oxygenating power 
of the respiration. I should think that an inflammation ten times 
more violent w r ould be incapable of producing so great an amount of 
constitutional disorder through any other means than those above 
alluded to, for the reaction of the heart and arteries occasioned by it, 
and the distress of the nervous system, occasioned by the perception 
of it, would be nothing, I was going to say less than nothing — were 
it not for the accidental interruption to the oxygenation. Therefore, 
I repeat that the slightest attack of coryza is worthy to be regarded. 

But the question arises what shall we do for the cure of this case; 
how shall we free the Schneiderian membrane from its hyperemia 
and hyperneuria ; how shall we prevent its follicles from furnrshinig 



636 CORYZA. 

this excessive amount of mucus, or how shall we take away the sub- 
mucous infiltration, which causes the cavities to collapse and defini- 
tively to close them? Will the vulgar remedy, greasing the nose, 
have this effect? Certainly the Student cannot rely upon such a 
therapia as that. Will he purge the child? Will he give it a warm 
bath? Will he apply a leech within the margin of each nostril? 
Will he give it diaphoretic remedies? Will he regulate the tem- 
perature of its apartment? Will he cause the aperture of the nostril 
to be kept free from the scales and incrustations produced at the 
orifice by the desiccation of the mucus that falls upon the very margin 
of the nostrils, and sometimes forms tampons or plugs running far back 
into the cavities of the head? It is well if he will do all these things; 
but experience, the best of teachers, will show him that such remedies 
have little power over the disorder, and the coryza goes on notwith- 
standing all his attempts. Will he produce a useful therapeutical im- 
pression upon the mucous passages by touching them with a delicate 
camel's hair pencil, dipped in proper solutions of nitrate of silver or other 
metallic salts ? Even these things fail, and often fail, but there is a treat- 
ment which experience, the best of teachers, has taught me never fails. 
I scarcely dare, in a formal work, pretending to a character of science, 
to say what this treatment is, and yet I must, with undoubting con- 
fidence, recommend the Student to adopt it. 

When a new-born child is seized with a coryza that attracts my 
attention, I invariably direct a skull-cup made of flannel, to be 
so constructed as accurately and perfectly to fit the form of the 
cranium. I direct this cap to be fastened upon its head, and to be 
left there for three days and nights, and I always feel sure that within 
about that time the coryza will have totally disappeared. I mean to 
say that the cap should fit the head closely — not loosely, for I desire 
that the air of the apartment should not pass freely under it. 

If the Student will try my method and fail, he can but be disap- 
pointed, which, I am confident he will not be ; if he adopts all or any 
of the other remedies that I have hinted at above, he will surely meet 
with disappointment many times — by my method never. 

It is hardly worth while to reason upon this subject, but let him 
read Dr. Denman's account of coryza, and the accounts contained in 
the treatises on the diseases of children, in order to learn how he can, 
in a better manner than that I have pointed out and more effectually, 
counteract the pernicious existence and tendency of this troublesome 
malady. 



CYANOSIS. 637 



CHAPTER XXIV 



CYANOSIS NEONATORUM. 



I begin by requesting the Student to take notice that the title of 
this article is cyanosis neonatorum, or the blue-disease of young chil- 
dren, and that I have no design herein to treat of all the affections 
that may in anywise serve to contravene the aeration of the blood — 
for all such diseases are causes of cyanosis. 

There is so great a variety of maladies that interfere with the 
due aeration of the blood, that a volume, rather than a short article, 
ought to be devoted to their consideration, in any attempt to describe 
all of them. — Malformation of the heart and its vessels — unnatural 
states of the lungs, whether congenital or accidental — tumors — 
hydropic collections — tubercles — vomicae — congestion — inflammation 
— whatsoever, in fine, prevents the due exercise of the whole function 
of respiration, may be set down among the possible causes of cyanosis. 
My intention is to treat only of those cases that are coincident with 
permanency, after birth, of the characteristics of the foetal heart. 

In the four great zoological classes, the mammals, birds, reptiles, 
and fishes, the circulation is effected chiefly by the force of a com- 
pound heart, whose economical purpose it is not merely to carry on the 
circulation, dispensing the blood and caloric into every part of the 
system, but in a pre-eminent degree to convey oxygen into every part 
and point of the system. 

In lower grades of being, as in the insects, and annelides, air is ad- 
mitted to the trachea through open stigmata on the surface of the body. 
These lower creatures require no mechanical apparatus or circulating 
force, to compel the air to enter the interior recesses of the tissues. 
It permeates tubes that are always open to admit oxygen to the or- 
ganic molecules. The higher orders of creatures could not exist 
without a complete machine competent to fulfil this indispensable 
design and purpose. Hence the birds and mammals are provided 
with lungs and a double heart, or rather with two hearts, one carbon- 
iferous, or venous, and the other oxygeniferous, or arterial. 



638 CYANOSIS NEONATORUM. 

In the reptiles there are, properly speaking, three hearts, of which 
one is venous, or carboniferous, another oxygeniferous, and the third 
mixed, propelling both the oxygenated and the undecarbonized blood. 
In fishes, the heart is absolutely venous, consisting of an auricle 
receiving the blood from the whole body, which it delivers into the 
single ventricle; whose office it is to inject this blood, in whole or in 
part, upon the oxygenating surfaces, called branchise, or gills, whence 
it flows off to the constitution, to return by the principal dorsal vein, 
to the auricle; the fish's heart, in this view, may be considered as a 
true pulmonic auricle and ventricle. 

T.he child in utero may, as to the nature of its sanguine circulation, 
be compared to the fish, or the batrachian. In very early stages of 
its embryonal life — not the very earliest — the heart consists of a double 
ventricle, equal to one ventricle, and of a single auricle. I say one 
auricle, since the auricular septum can hardly be said to exist, and 
the two auricular cavities are virtually one. I also said that it has a 
double ventricle, each of the cavities of which lends its energies to 
the systemic circulation. In the beginning, the pulmonary artery — 
which is really a ductus arteriosus — and the aorta equally concur in 
the production of the systemic circulation; both ventricles being 
required to give impulse to a circulation necessary to the rapid 
development of the constitution, and drive the blood to the distant 
capillary tufts of the placenta and back again to the heart. With 
the progress of the intra-uterine life, the pulmonary artery becomes 
developed upon the ductus arteriosus, which loses by degrees its 
transitive importance, and is laid wholly aside at birth as a no longer 
useful machinery of the circulation. 

The aeration of the embryonal and foetal blood depending on the 
placenta, a machinery is required to get the oxygeniferous blood of 
the placental tufts out of the venous into the systemic circulation of 
the child, and another apparatus to turn over its venous or carboni- 
ferous blood into a part, not the whole, of the systemic circulation, 
which alone can transfer it to the aerating tufts of the placenta ; there- 
fore, in the child somewhat advanced in its uterine life, there is of ne- 
cessity a crossing of the currents of oxygeniferous and carboniferous 
blood, in the right auricle, and a direct channel of transfer from the 
right ventricle to the aorta. 

The blood of the umbilical vein, mixed with that of the inferior 
cava, enters the posterior, right, lower segment of the right auricle 
behind the right extremity of Eustachi's valve, which conducts it 
across the cavity to the fossa ovalis, leading it through the foramen 



CYANOSIS NEONATORUM. 639 

ovale. The current lifts Botalli's valve, which is on the left face of 
the septum, to pour itself out into the systemic auricle. The left ven- 
tricle receives it, and thence it is conducted by the carotids and 
vertebrals to the encephalon. 

This is the best blood of the foetus. It is not highly aerated ; 
probably, not so highly as that of the Reptilia, consisting as it does 
of the deoxygenated blood of the portal circulation, and of that of the 
lower extremities and pelvis, and animated only by the slight endow- 
ment of oxygen it could acquire in the placenta, from whence it is 
derived by the umbilical vein. 

Imperfectly aerated as it may be, it is to a certain extent, the oxy- 
geniferous fluid of the foetus, and is capable of developing the torpid 
innervations of the embryo and foetus, which are, perhaps, far inferior 
in intensity to those of the chelonians and other Reptilia; doubtless, 
far inferior to those of many tracheal creatures and infusorials. 

Having made its route to the encephalon and superior extremities, 
where it has given out its oxygen, the blood has become thoroughly 
venous, and returns to the right auricle, into which it plunges at the 
superior part of the sac, in front of Eustachi's valve, and opposite to 
the iter ad ventriculum dextrum, through which it flows, while the 
current from the inferior cava passes through the foramen ovale behind 
it, and at right angles to it. 

The right ventricle is filled then with the venous blood of the head 
and upper extremities, which it injects, by the pulmonary artery, vir- 
tually the ductus arteriosus, into the aorta, below the giving off of the 
carotids and subclavians. Thus it arrives again at the placenta. 

In this crossing of the currents in the auricle, there is a partial 
mixture, but it is presumed to be only partial. 

It is probable that a major part of the blood from the ductus venosus, 
mixed with that of the hepatic veins and inferior cava, is directed 
upon the head and superior extremities, though it is true that a portion 
of it turns over the aortic arch to be mixed with the current from the 
ductus arteriosus. It is, indeed, essential that this should happen, 
since otherwise, the whole of the digestive, renal, and pelvic branches, 
as well as those of the inferior extremities, would otherwise be as- 
phyxiated. 

This admirable arrangement, by which the systole of the left ven- 
tricle propels both the arterial blood to the brain, and the venous blood 
to the placenta, must necessarily persist throughout the gestative life; 
for, should it cease previously to the birth, the foetus would inevitably 
perish, while its persistence after birth, would be equally fatal. 



640 CYANOSIS NEONATORUM. 

The foramen ovale affords the sole normal route of the arterial blood 
from the placenta towards the brain. 

Hence, the foramen ovale is persistent in the foetus. 

Hence, also, the child is born with an open foramen ovale. 

But the foramen is provided with an operculum or valve. 

The valve, called valve of Botalli, lies upon the left wall of the 
septum auricularum. 

When the valve is shut, the opening is closed. The lifting of the 
valve re-opens the aperture. 

If the valve be closed before the establishment of the respiratory- 
life, the child dies from absence of oxygen in its brain, for the oxygen 
of the placenta cannot reach the brain by any other route. 

The valve remains open for many days after the birth of the child, 
three, ten, twenty days; and it may be open seventy years in some 
cases. 

As, in the uterine life, aerated blood passes through the foramen, 
so, in the respiratory life, carbonated blood, if any, passes through 
the opening, to fill the left auricle. Whenever the left auricle is 
filled with venous blood, it is injected by the systemic ventricle into 
the brain and the whole system. 

Such injections produce cyanosis. Cyanosis is a state of non- 
aeration, more or less complete and universal. Cyanosis of the 
capillary system of the brain, is true asphyxia. 

The degree of intensity of the blue color in cyanosis, is not a certain 
criterion of the effect produced by the malady. 

One individual may tolerate a greater degree of cyanosis than 
another, with less inconvenience and distress than that other indi- 
vidual. 

I repeat that cyanosis, whether general or local, is a degree of as- 
phyxia of the parts exhibiting the phenomenon. Blue hands from 
cold weather, blue finger-nails from ague, from cholera, from drunken- 
ness, or etherization, is asphyxia of those parts severally. Asphyxia 
of the capillaries of the skin, or of the extremities, is not inconsistent 
with life. But, asphyxia of the encephalic capillaries, when carried 
to a certain extent, is mortal. Mortal asphyxia is always so because 
the capillaries of the brain are then the seats of the malady. 

This I consider to be true, because the asphyxiation of a limb by 
means of the tourniquet is not suddenly mortal, it does not speedily 
destroy life, it only arrests development; whereas carboniferous blood 
in the capillaries of the brain destroys life instanter, if it be wholly 
and only carboniferous. 



CYANOSIS NEONATORUM. 641 

Many children at birth, or soon after delivery, discharge the blood 
of the right auricle into the left auricle, in consequence of asynchronous 
action of the heart. 

In such cases, to shut down the operculum or valve of Botalli, is to 
arrest the flow and cure the patient for the time being, or for all future 
time. 

In November, 1832, the year of cholera, I had charge of the case 
of Mrs. Taylor, No. 503 North Fourth Street. She was about seven 
and a half months gone with child, when she was seized with symp- 
toms of the prevailing epidemic. She was violently attacked, and 
became also affected with symptoms of premature labor, which at 
length led to the expulsion of the foetus. 

The child was alive, but began to turn blue under its respiration. 
As the cyanotic hue became more intense, the phenomena exhibited 
by its innervative forces turned more and more unnatural, so that, 
employing only faint and imperfect aspirations, often suspended; 
becoming convulsed, and having feeble, scarcely perceptible pulsa- 
tions, it seemed at the point of death. 

The young mother, who was still ill with her cholera, could not be 
insensible to the danger of the child, and I perceived that the com- 
plication of a psychological with her other irritations, might render 
the cure of her own malady more difficult, if not impossible. It 
became, then, in view of the mother's position, a matter of great 
moment to rescue the child from an apparently imminent death. 
These reflections, which I made at the time, gave me great pain; — 
for, while I deemed the state of the child one of partial asphyxia from 
the mixture of its venous with its arterial blood, the mixture being 
made by injection through the foramen ovale of the auricular septum, 
I could devise no treatment upon which to rely for obviating that 
injection. 

I was deeply concerned, and knew not what to do; suddenly I 
reflected upon the structure of the fcetal heart, and the route of the 
foetal circulation, and I said, if I bring the septum auricularum 
into a horizontal attitude, will not the blood in the left auricle press 
the valve of Botalli down upon the foramen ovale, and thus save the 
child, by compelling all the blood of the right auricle to pass by the 
iter ad ventriculum, and so to the lungs to be aerated? 

Having practiced midwifery for many years, I had on many occa» 

sions witnessed the fatal termination of cyanosis neonatorum, both in 

the premature and the mature child. I had seen children at five, and 

at five and a half, at six, and at seven months, vainly attempting to 

41 



642 CYANOSIS NEONATORUM. 

carry on respiratory life, and found them all to perish with the signs 
of cyanosis, whether from too large a foramen ovale, or from imperfect 
development of the respiratory machinery of the lungs by atelectasis. 

In the case now under consideration, I placed the child, which 
seemed nearly dead, upon a pillow, on its right side, the head and 
trunk being inclined upwards about twenty or thirty degrees. 

Upon placing it down in this manner, it became quiet — began to 
breathe more naturally; to acquire a better hue of the face, hands, and 
feet; until, in a very short time, it was quite well again, and did well; 
having no further returns of the attack of cyanosis neonati. 

I shall not conceal the satisfaction I derived from the successful 
result of my reflections, thus put into practice, in the case; for I 
thought, and I still think, that the child would have died inevitably, 
but for the treatment. In very many instances, during a long obste- 
tric experience, I had never made such a reflection upon the means 
of saving the blue child, of which I had seen so many cut off. I 
believed, and I still believe, that I was the first to invent the treat- 
ment; and thus the first case in which I put it in practice, was 
eminently successful. I am not aware that any other person had 
before suggested it, though in his account of cyanosis, M. Gintrac 
gives in case 5th an account of Dr. Wm. Hunter's patient, set. 8, who 
obtained relief from a paroxysm, by lying still upon his left side, 
which always relieved him. After his death, the ventricular septum 
was found to be wanting, or rather perforated near the base of the 
heart, so that the aorta received the injection of the right, as well as 
of the left ventricle. — Vide Gintrac, p. 33. 

Six years later, in my Philad. Pract. of Mid., edit. 1838, I pub- 
lished some remarks on cyanosis, or blue-disease, which being written 
in much haste, I did not at the time remember the circumstances of 
the above case, which occurred in Nov. 1832, in Fourth Street above 
Poplar, No. 503, in a child of Mr. Taylor, a builder, formerly of this 
city. 

Since the date of my first application of this method, 1 have had 
numerous occasions to put it in practice, and not a few opportunities 
of examining the state of the heart after death, in some of which, after 
vainly applying the treatment, I came to the conclusion that other 
causes, not patency of the foramen ovale, must exist, to contravene 
the curative tendency of the method. 

My publications — and my explanations to friends — with the lectures 
on the subject that I have now delivered to many hundred students 
of medicine, have rendered my treatment a popular one — to such an 



CYANOSIS NEONATORUM. 643 

extent, that, in various States of the Union, the treatment is become 
a familiar one. Many monthly nurses have become acquainted with 
it, and I presume it is so divulgated throughout the land, that children 
suffering from the malady will very generally have the advantage of 
its application, if it be really advantageous, and this the more pro- 
bably, since no reasonable objection could be found to the putting of 
it in practice. 

I make these remarks, founding them upon various letters I 
have received from gentlemen in the differen Sttates of the Union; 
from conversations, and from statements made to me by medical 
Students on their arrival here, in the autumn, of cases treated by their 
instructors. 

This explanation w T ill show that I am warranted to say, that my 
invention has become extensively known, and is to a reasonable extent 
understood and practiced in this country; the more especially as it 
has been reported by many hundred Medical Students, that are now 
settled in the north, the south, the east, and the west. 

The following is extracted from a letter to me dated Pittsburgh, 
Dec. 7, 1838, from Dr. W. F. Irwin. 

" The second item of information derived from your work is 
that in which you lay down the only rational explanation and mode 
of treatment for that formidable disease of infants called ' morbus 
cceruleus.' During a practice of twenty-five years, I have had 
about tw T elve cases. In one family I lost two cases in succession, with 
an interval of two years. In this family there appeared to be a sin- 
gular tendency to the disease. From the mother's account I should 
conclude that out of six deaths in her family, five must have died of 
morbus coeruleus. In deference to authority I have generally pursued 
the plan recommended by the late Dr. Hosack, which may be seen in 
the Appendix to Thomas* 's Practice; and I must say that I was never 
satisfied with it, as it appeared to me to have no sort of adaptation to 
the then received pathology of the disease. In some cases, I have 
thought that a tepid salt bath produced a beneficial change in the 
color of the skin, and in the respiration. In two cases a tablespoonful 
of blood drawn from the cord seemed to have a good effect. In a 
case that occurred in August last — the child, which had been well 
for five or six days, suddenly changed color — had laborious and in- 
terrupted respiration at long intervals. I was sent for immediately, 
and ordered a warm salt bath, in which the change of color from 
blue to the healthy tint was remarkably rapid. The attending 
physician came into the room while I was engaged, gave some 



644 CYANOSIS NEONATORUM. 

powders, and the infant died. In October last I had a strongly 
marked case in the afternoon at about six o'clock As soon as the 
nurse announced the condition of the child, I had the washing sus- 
pended, and ordered the child to be placed on its right side and to be 
left undisturbed until the following morning. At my visit next day, I 
found the infant healthy in every particular, and it has continued so until 
the present time. I have been so pleased with what I deem your 
philosophical mode of treatment and its success in the above case, 
that I could not refrain from communicating the result." 

I have now before me a letter from Paul F. Eve, M. D., Prof, of 
Surgery in the Medical College of Georgia, dated Augusta, Feb. 2, 
1848. In this letter, Dr. Eve informs me that he was in attendance 
22d Nov., 1847, upon Mrs. C, then affected with premature labor of 
an uncertain date of gestation. The child, a male, which was born 
after an easy travail, weighed between five and a half and six pounds. 
The testes were not yet in the scrotum. The respiration was at first 
carried on by sighs repeated once in five minutes. The child was 
once supposed to be dead, and given up as lost; but by breathing 
into the lungs it revived, and then upon being laid upon its right side, 
where it was kept during four days, it perfectly recovered, and was 
healthy at the date of the letter. It was not dressed for three days. 
Every motion, for some time after its birth, would produce the 
cyanosis. Dr. Eve is inclined to believe it was six and a half months 
in the womb. 

Feb. 11, 1848. Mr. S. C.'s son, set. 11 weeks. Very stout and 
healthy since his birth. Was vaccinated on the 3d instant, and has 
now a full sized vesicle and areola; slept badly last night. This 
morning was much agitated and cried long — became blue as to the 
whole face — moaned for a long time. His mother supposed he " was 
going into a fit," and could not otherwise account for his strange ap- 
pearance. (She has had six children.) 

The child was crying when I arrived. The upper lip was very 
livid, and the countenance wore an air of distress. I laid it down 
upon its right side; it became quiet and the livid areola vanished. I 
turned it on the left side, and the dark livor of the upper lip reap- 
peared. Upon rolling it on the right side again the color disappeared, 
but returned when I replaced the infant on its left side. I gave it 
a teaspoonfulof oil, with orders to lay it on the right side. Feb. 12th. 
Had a good night, and seems well to-day. In dressing it, the mother 
says, it became livid. She observed that it was on the left side, but 
upon turning it on the right it recovered and has been well ever since. 



CYANOSIS NEONATORUM. 645 

Jan. 3d, 1849, I believe this child has had no indisposition since 
the foregoing date. 

In March, 1848, I attended Mrs. G. T , who was at the time 

delivered of a child at six months and ten days. It was deeply 
cyanosed for four days after its birth. The nurse kept it almost wholly 
reclined on its right side, and the infant, now about nine months old, 
presents a good prospect of a successful rearing of it. In this case, 
the child was certainly relieved when laid upon the right side. 

In the early part of the year 1848, I delivered Mrs. , 

Thirteenth Street, of a foetus at six months. It breathed well at first, 
and uttered loud cries. But cyanosis came on the third day. I 
many times caused the livor to disappear by turning it on the right 
side, and made it return by rolling the child gently over to the left side 
and vice versa, as often as I repeated the experiment. It died after 
some days. The foramen ovale was slightly open, and the lungs 
partially affected with atelectasis. 

Here is another letter, dated Antrim, Alleghany County, Penn., 
Feb. 11, 1848, which was addressed to me by Dr. S. Schreiner, a 
graduate of the Jefferson Medical College. 

"Mrs. A. S r was delivered on Tuesday, Jan. 11, 1848, at 

.7 P. M., of a male infant. Nothing peculiar transpired during the 
gestation or delivery. Parents healthy; mother quite lusty. Sup- 
posed weight of the child about eight pounds; it seemed of full age, 
healthy, and well to do. About 9 P. M., it seemed to have a violent 
attack of colic; cried violently. All attempts to pacify it were vain, 
until about midnight, when it became quiet, and was laid in bed 
behind the mother, where it remained until about 8 A. M. on Wed- 
nesday. At that time the mother awoke, and thinking it breathed 
strangely, asked the nurse to take it up, to see what was the matter. 
She did so, and observed that it was of a dark-purple hue ; the breath- 
ing seemed to cease; it was strongly convulsed, the fingers being 
clenched firmly against the palms of the hands." 

Dr. S. informs me that the child was now removed from the lying- 
in chamber, in order that the mother, after she had been told it was 
dying, might not witness its last agony. 

"Upon remaining so for some time, it gasped for breath, the 
purple discoloration faded from it, and the paroxysm was over. It 
remained quiet, without any motion whatever for about three hours, 
when the fit returned again; and again it did so, each paroxysm con- 
tinuing longer and increasing in intensity until Thursday (the following 
day), between four and five P. M., at which time I first saw r it. Dur- 



646 CYANOSIS NEONATORUM. 

ing this time it had seventeen attacks, the duration of the last one 
being over forty minutes. The attacks returned at intervals of a 
little more than an hour. 

" Its appearance, when first seen, was as follows. It laid motion- 
less upon a pillow in the nurse's arms; pulse irritable; cheeks suf- 
fused with a scarlet flush; respiration short and quick; (it seemed as 
if fever was present;) dusky color of the skin, except the bright spot 
on the cheeks. Soon its face, then its body and limbs, became of a 
dark purple or nearly black color ; respiration, a short gasp at long 
intervals, gradually increasing until it was altogether suspended for 
twenty minutes ; pulse grew fainter and fainter, until it ceased at the 
wrist, and the heart only gave a heavy throb at long intervals. 
Gradually the pulse became (again) perceptible at the wrist — the 
discoloration vanished, and the paroxysm was over. 

" Though the parents and all present declared there was no use 
in attempting anything for its relief, they consented that a trial should 
be made. I had it laid in the position recommended by you in your 
course of lectures, and in your Phil. Prac. of Mid., upon the right 
side, at an angle of 30°, enjoining strict adherence to the position. 

" From its flushed appearance, and the congestion seemingly 
present, I should have recommended leeches, had they been at com- 
mand. I remained long enough for another paroxysm to have taken 
place, judging from the previous intervals, but it did not take place. 
During this time it attempted to cry, but made no sound whatever, 
though it seemed to cry violently. After this it passed some meco- 
nium, and took a little milk and water which it sucked from a rag 
placed in its mouth. I was told these were the first motions of the 
kind it had made for twenty-four hours. They had before poured 
some nourishment down its throat, but it appeared to bring on a fit, 
and they desisted. ■ I saw it again the next morning. It had two 
returns of the disease ; so very slight, however, as only to be observed 
by the face becoming darker; but they continued only a few minutes. 
I should not forget to mention, that after each of these, perspiration 
ensued; slight attacks first, but after the second very copious. 

" Pulse at this time appeared normal ; respiration easy, but somewhat 
quick. I saw it again to-day. Has had no return of the paroxysm, 
and is in excellent health, with the exception of an occasional attack 
of colic." 

I shall now offer some observations on the circulation of the blood, 
in order to sustain the position I have taken as to the influence of the 
child's attitude in curing it of an attack of cyanosis neonati; and I 



CYANOSIS NEONATORUM. 647 

shall do this, not merely to defend my opinion and practice against 
the opposition of those who deny the utility of the precept, and the 
reasonableness of its doctrine, but because, while it has been, in my 
hands, the means of rescuing many children from death, it has also 
led me to entertain views of the pathology and treatment of certain 
disorders which I desire now to express, hoping they may become 
useful to the public, and to my brethren generally. This I shall do 
notwithstanding it may expose me to the charge of useless iteration ; 
for I desire not to ask the Student to turn back to the former pages of 
my book ; but rather, that he should perpend my explanation in this 
one chapter. 

In contemplating a living body, we are struck with the conviction 
of its complex nature and attributes. We behold it as consisting of 
various parts and organs, each endowed with powers of its own, and 
each charged with some especial function, the due and harmonious 
exercise of which by all the organs represents a state of health, while 
an imperfect or irregular performance of any of these offices is indi- 
cative of a condition of derangement, disorder or disease. 

In contemplating such a being, in whatever grade of the zoological 
series it may be stationed, we are compelled to admit that of its parts, 
some are of more and others of less importance. It has parts that 
might truly be called noble, and others that are common or vile. 
Whether it be an annelide, or insect, a radiate, vertebrate, reptile, 
fish, bird or mammal, the Ens, the living creature, the Verb — that 
which can do, be, or suffer, of it, is composed of the nervous mass of 
the creature, which is noble, and all the rest is vile, common and of 
less account. 

To look upon the Figures at page 4 of Milne Edwards' volume 
on the Invertebrata, wherein he has represented the nervous system 
of an earwig, a grasshopper, &c, one sees the real abstract animal, 
deprived of all save its nervous mass, which alone is the patible, 
sensitive, and perceptive being, while all the rest of the constitution 
of it being taken away, it has thereby lost only its servitors — its pre- 
hensile, locomotive, digestive, reproductive, aerating organs. The 
nervous mass — the creature — the Ens, is left entire — naked — alone, 
in an abstract state. 

This idea of a creature, abstracted from its armature, its engines 
and agents, is by no means a novelty, and it has the sanction of the 
wisest men — such as Cuvier, Lorenz Oken, and others. It is upon 
this idea of the creature, as consisting essentially of the nervous mass, 
that all modern zoological classification depends, and in fact, the 



648 CYANOSIS NEONATORUM. 

whole regne animal of the illustrious French naturalist has derived 
the exact method and order of its arrangement from a view of the 
disposition of the nervous system of its integral individuals. In the 
higher orders of the vertebrata, the number and magnitude of the 
organs are greatly augmented above those of the simpler existences. 
A medusa, an actinia, a holothuria, or a polyp is, equally with the 
most elevated mammal, composed essentially of a nervous mass, 
which in some without, and in others with a centrical sensorium, 
exists either by means of disseminated nerve points, or by a ganglionic 
and filamentous system of innervations. 

In the human being, the nervous mass is the cerebro-spinal axis, 
and the sympathetic and plexual system, with all the nerve-fibres that 
blend their distal extremities, or reflect their fibrillar in the substance, 
or on the surfaces of the tissues. The heart itself and the stomach 
are but portions of the nervous mass, enveloped, like the gem in 
geology, in the gangue of the cellular, muscular, mucous, or fibrous 
tela. 

The same is true of the alimentary, respiratory, secretory, absorbent, 
sensual, and reproductive organs — of which an ultimate anatomy 
ought to seek to expose and make manifest solely the nervous portion 
of its mass. 

The whole brain and cord — the pneumogastric, the trifacial, and 
the phrenic nerve — all the arches of the great sympathetic — every 
ganglion "plexus, and fibrilla, are either conductors or generators of 
biotic force. 

But, whether conductors or generators, it cannot be denied that 
they are in a degree generators, since all nervous mass is a generator. 

In either case, the material vile parts which they innervate, owe, not 
their existence only, and their development to the nervous mass with- 
in them, but every modification of their vitality, every shade of their 
life modality, may be assigned to a status of the supplying and sus- 
taining: nervous mass. 

In the series of creatures, rising from the lowest infusorial, we find 
at the summit of the scale, man with his concentrated cerebral, or 
cerebro-spinal nervous mass, by means of which he is rendered 
capable not only of impression, but of conscious perception, and of 
free-will; of reason and judgment, with all the powers of the intelli- 
gent mind. 

It is for the conservation of this nervous Ens — this nervous mass, 
as Oken denominates it, that its servants and ministers the anatomical 
organs and histological tissues are added to it, as its endowments and 



CYANOSIS NEONATORUM. 649 

properties. IT is the seat and source of their vitality. 
They are regulated and maintained in a co-ordinated 
life by ITS biotic force. 

When that biotic force fails, they fail likewise ; when it dies, they 
also perish; when it recovers its energy, they resume their powers, 
and perform their offices for its conservation — its protraction — its 
sensation — its consciousness — its free-will — its reason — judgment, 
imagination — its hope and its charity — its fore-thought — its retrospec- 
tion — its self-complacency, and its remorse. 

But what is this nervous mass? 

Oken says, " The origin of the animal is from the nerves, and all 
anatomical systems are only free evolutions or separations from the 
nervous mass. The animal is naught but nerve; what it is fur- 
ther, or in addition, is obtained elsewhere, or is a metamorphosis of 
nerves." " When, also, the other systems have been formed out of 
the identical nervous mass, still the whole animal body is naught but 
nervous mass, only, in a crude or inert condition. There is, conse- 
quently, no point upon the body, on which some nervous phenomena 
are absolutely wanting, or where they may not appear, under certain 
relations.' 7 — Physio -philosophy, page 330. 

I shall not encumber these pages with quotations from the autho- 
rities, to fortify the assertion that the nervous mass is the essential 
Ens. The asseverations of a thousand philosophers would not make 
more or less true, a proposition which commends itself to the mind, 
acting upon its own perception and judgment of a dogma declared 
to be true. Such a truth is not proved by evidence, nor established 
by any method of induction. It is a truth of reason — it is a truth of 
consciousness — it is in the same category with the cognition of our 
personal identity. 

Taking the dogma for granted, therefore, I shall proceed to show 
that the cerebro-spinal axis in man, is inert and powerless, nay, life- 
less, exanimate as of itself; and that it depends upon the influence 
of oxygen for its power to manifest itself in its life-phenomena. 

The same Oken has said that " the blood is the fluid body;" and 
that " the body is the fixed and rigid blood." 

These expressions are equivalent to the assertion that the histolo- 
gical materials of the body are derived from the blood, and no one 
will deny the proposition. Even the nervous mass itself is developed 
and maintained in volume, form, and weight, by supplies from the 
sanguine mass ; but the oxygen of the blood is the agent by which 
the force of nerves is brought into play. The oxygen taken up in 



650 CYANOSIS NEONATORUM. 

the act of respiration, and carried into the arterial or aerated blood, 
is transferred to the brain by the arteries, and there its contact or im- 
miscence with the material essence of the brain, is followed by the 
extrication of the power, or nerve-force. In this view, an artery is 
not a mere sanguiferous tube, it is an oxygeniferous tube, and it car- 
ries that principle everywhere throughout the body. 

The respiratory organ, in this view, too, is but the oxygenating 
apparatus, though it thus produces the double effect of endowing 
the blood with its oxygen, and at the same time developing the animal 
heat, while it also eliminates a portion of the somatic carbon. The 
highest function of the respiration is the oxygenation of the nervous 
mass. 

M. Cerise, in his paper, Sur la Sur Excitation JVerveux, Mem. de 
VAcad. Roy. de Med., avers that to the blood in the brain, is due the 
extrication of the life-force, the nervous force. This doctrine is not 
true, if hypothecated as of mere blood; since carbonated or carboni- 
ferous blood — venous blood in the capillary vessels of the brain — is 
incapable of effecting the least evolution of power from the nervous 
mass. Oxygeniferous blood is all-powerful for its extrication. Hence, 
since blood, merely as such, cannot generate the life-force, while 
aerated blood can do so with absolute perfection ; we have a clear 
inference to the opinion that it is the oxygen which is the agent ; and 
that, by a plain induction of facts, all of which, without exception, 
concur to declare that oxygen is indispensable to the exertion of a 
life-force — -force-vitale. — Lebenskraft. 

Nothing lives, save in the presence of oxygen. It is even true that, 
the spiritual soul being present, all life is a result of a process of 
oxygenation. Hydrogen azote, chlorine, nor carbonic acid cannot 
evolve nor sustain life. Oxygen is the vitalizing, not the vital prin- 
ciple. It is the cosmic reagent for producing vitality out of nervous 
mass. 

Mons. Le Gallois has, at page 142, the following words: — 

" Life is produced by an impression of the arterial blood made 
upon the brain and the medulla spinalis, or by a principle resulting 
from this impression." Also, " The prolongation of life depends upon 
the continual renewal of this impression," &c. I suggest that arterial 
blood is not different from venous blood, save as containing a larger 
quantity of oxygen, and that it is the oxygen to which M. Le Gallois 
refers, and not the blood which contains it. 

If it be not a mere fancy in Oken to say that the " artery is an air- 
tube;" and, if it be true that the blood excites in the brain the forces 



CYANOSIS NEONATORUM. 651 

which, irradiating the organs through the nerves, makes manifest in 
them the various motions, and allows in them the impressions and 
perceptions that we suppose to be life ; then it is conceded that modi- 
fications of the blood, as oxygeniferous, are capable of modifying the 
state of all the organs, and not of them only, but of all the histological 
integers of which the sum of a body is composed. Where the blood 
is healthful and normal, it will in so far as to a dependency upon the 
blood, produce a perfect innervation, and vice versa. Supposing the 
blood to consist of the four constituents fibrin, discs, albumen, and 
water, in the proportion of fibrin 3, discs 127, albumen 80, and water 
790 to the 1000 grains — any change in the constituency of the blood 
cannot but modify its power to take up and carry oxygen to the parts, 
and so to the brain. 

A patient who has suffered from exhausting hemorrhage, whether 
traumatic or active, will, in consequence, be deprived to a certain 
extent of the ability to extricate the nerve-force. 

If, through any faulty arrangement of the great vessels of the heart, 
the venous blood returning from the systemic circulation, be thrown 
back upon the system, without being newly exposed to the oxygenating 
apparatus of the lungs, the nervous mass, failing of its supply of 
oxygen, will fail in part, or die, according as the want is less or more 
incompletely supplied. 

Air, that in a given number of cubic inches contains less oxygen 
than is required for healthful respiration, cannot be breathed without 
diminishing the power to extricate nervous force. Thus a traveler 
ascending a lofty mountain, finds his strength to be diminishing, in 
proportion as he rises above the sea level, and when he is at an ele- 
vation marked by 18 or 20 inches in the barometer, he finds so little 
oxygen in his aspiration, that he is compelled to stop, and even to sit 
down, after walking only a few feet — because the ordinary aspiration 
at 16 or 18 inches consisting say, of 20 cubic inches of rarefied air, 
is equivalent, in the amount of oxygen it contains, only to an aspi- 
ration, perhaps, of 6 or 8 inches at the base of the hill, where the 
mercury marks 30. The traveler pants for breath, which means to 
say that he breathes frequently, in order to get his required amount 
of oxygen. That amount which cannot be ingested with twenty res- 
pirations, he seeks for in forty or eighty respirations per minute, for 
without the requisite amount, he cannot extricate the nerve-force, nor 
will his muscles obey the dicta of his free-will — his volition — he is 
compelled to stop, to sit down, or even lie down, whereupon, con- 



652 CYANOSIS NEONATORUM. 

suming less of his nerve-force, he recuperates for another effort. 
This was the case with the party of Dessaussure on Mont Blanc. 

That which happens to the traveler on the mountain summit, occurs 
to the ansemical girl at the sea-level. His blood cannot find sufficient 
oxygen in 20 inches of rarefied air; her blood will not receive it, though 
it be contained in the 20 inches. 

But, if the blood be as perfect as possible in its constitution, or 
crasis — and it fail to be exposed to the oxygenating pulmonary sur- 
faces, it can by no means excite in the brain those quantitative results 
as to the production of the nerve-force, that are required in all these 
cases, whether of a low barometry, an anaemia, or a want of oxygen; 
there is failure to supply the essential reagent — the oxygen. 

A copper and zinc plate, or a series of such plates, constitute no 
galvanic pile if plunged into milk, or olive oil. They are energized 
by immersion in a saline or acid solution ; so, the substance of the 
brain, the nervous mass, has no activity when bathed in streams of 
carboniferous blood ; it is quiescent ; it is indifferent ; it is aperceptive 
of the presence of such a fluid ; but, when the oxygeniferous stream 
of the arterial fluid is injected into its tissues, it instantly becomes 
instinct with life and power under the reagent, and streams of biotic 
force flow off through the nerves to all the subject organs; or the free- 
will has power to urge the innervations to their utmost bounds of 
strength and precision. 

An uninterrupted current of organic innervations, flows from the 
whole nervous mass, whether cerebro-spinal, or sympathetic. But 
there is a free-willing innervative force, that appertains only to the 
great bulbs of the spinal axis. What that free-will is, is known to 
God alone — it is an appurtenant and faculty of the soul, whose whole 
nature is unknown to us. St. Paul admits that we know not " what 
we shall be," when the soul shall have been disenthralled of the 
shackles and obstructions of the mortal body; we know not what we 
shall be, though we are conscious that we shall be. We do know, 
at least, that we shall be both conscious and free-willing existences. 
These, therefore, are qualities or faculties of the soul, exercised 
through the nervous mass, under the force of the great cosmic reagent 
Oxygen. 

From the foregoing, it appears that the presence of the arterial 
blood in the systemic vessels of the encephalon and spinal axis is as- 
serted to be a requisite for the evolution of the biotic force, as far as 
that force proceeds from the brain and cord. It requires no further 
proof, after the experiments of Wilson Philip and Legallois. 



CYANOSIS NEONATORUM. 653 

I have already said that numerous explorations of the bodies of 
neonati have shown that the foetal characteristics of the auricular 
septum are not entirely laid aside until after the third day, and often 
not until after the tenth and twentieth day; and, that in some persons 
it remains unclosed until the latest date of advanced age. It is, how- 
ever, covered by its valve. 

This may show that there is no inevitable inconvenience connected 
with persistence of the opening after birth, which is a physiological, 
not an accidental, nor a morbid condition; it is common to all the 
placental animals, and in all of them continues during a certain por- 
tion of their respiratory life. 

In myriads of children, its openness is attended with no incon- 
venience; nor would any inconvenience result, even in the absence 
of the valve, provided such patency should not be followed by mixture 
of the venous and arterial blood, which could not happen under a co- 
ordinated innervation of the symmetrical halves of the heart. Gintrac, 
page 238, says: " Toute communication entre les cavites droites et 
gaudies du cceur n'est pas inevitablement suivie du passage du sang 
noir dans les voies affectees du sang rouge ;" and, at page 240 he says : 
" The auricles first, and next the ventricles of the heart, contract at 
the same instant of time. If their force is equal, and the apertures 
through which the blood is to flow, be unobstructed, the fluid will not 
deviate, one way nor the other; a perfect equilibrium prevails 
between the sanguine columns; they oppose to each other an equal 
resistance, and each one follows the course naturally belonging 
to it." 

These are undeniable facts ; yet an open foramen ovale is accused 
as the cause of cyanosis neonati. 

Is this a contradiction in terms? Let us inquire. 

The heart is a machine — a hydraulic engine, provided with an 
auricular septum and valve, under which, during nine months of 
foetal life, flows a stream of aerated blood — no one denies it. At 
birth, the stream, in some instances, becomes carboniferous — no one 
denies it. But that venous current cannot but inundate the encephalic 
capillaries, whence all the modifications, not only of the hue, but all 
the strange manifestations as to the nervous force — in the respiration — 
and in the muscular action, calorification, &c. &c, that we observe in 
cases of cyanosis. 

The heart is not an asymmetrical, but it is a symmetrical organ; 
it has a zygo-zoar nature. In health, the two symmetrical halves 



654 CYANOSIS NEONATORUM. 

of it are innervated in the same times, and with equal force or in- 
tensity. 

But the synergy and the synchronousness may become asynergy 
and asynchronism, under circumstances of disease, or irritation, or 
faulty crasis or constitution, either of the organ itself, or of the nervous 
mass — or of the blood. 

The heart is the frequent seat of convulsive innervations, or of 
asynergic and asynchronous action. 

If the left auricle should act with greater force, or earlier, or 
more rapidly than the right, the blood in its cavity would press 
down the valve of Botalli, and cause the fluid to escape into the 
systemic ventricle only, and this is its natural state and rate ; but 
if the right auricle should act with greater force, in earlier time, 
and more rapidly than the left, it is not to be denied that the 
carboniferous blood would in part, and perhaps chiefly, escape into 
the left auricle from whence, being received into the systemic 
ventricle, it would hasten to deluge the brain, and the whole body 
indeed, with its non-oxygeniferous streams. Can anyone doubt that 
this was the case in the young girl, cited by Gintrac from Morgagni, 
Epist. xvii. No. xii. It is the first case in Gintrac. A girl died at 
the age of about sixteen years. She had been sickly from her birth; 
always breathing with difficulty, on account of her extreme weakness, 
and always exhibiting a livid color of the skin. The heart was small, 
and with a rounded apex ; the left had the ordinary shape of the 
right ventricle, while the right had the characteristic appearance of 
the left ventricle. But the pulmonary ventricle, although the largest, 
had the thickest walls. The right auricle was also twice as large, 
and more fleshy than the left. Betwixt these two cavities, was a 
foramen ovale large enough to admit the little finger. The valves of 
the pulmonary artery were morbid, leaving an opening not bigger 
than a lentil for the transmission of the blood. 

In this case, the largeness of the foramen ovale may be supposed 
to have some relation to the constriction of the pulmonary artery, 
whose constriction preventing the pulmonary ventricle from readily 
discharging itself, equally prevented it from receiving freely the dis- 
charges from its auricle. The auricle, therefore, injected the fluid 
into the left auricle, and thus kept the foramen free and large ; or, on 
the other hand, let us suppose that the foramen, being originally so 
large as to allow of the escape through it of most of the blood re- 
ceived in its cavity, there was not left a sufficient quantity to keep 
the orifice of the pulmonary artery duly open. In such case, the 



CYANOSIS NEONATORUM. 655 

orifice of the pulmonary vessel would inevitably diminish in size, as 
in Gintrac's case just mentioned. There is no extension of any living 
tissue save by the power of an esoteric or antagonistic force. If all 
the blood of the auricle should flow off through the septum, the pul- 
monary artery would ultimately become a ligament, as happens in 
the transitive tube called ductus arteriosus. 

The passage of blood to the lungs, which in the case cited by 
Gintrac, w^as not bigger than a lentil, prevented a full aeration of the 
blood, a fault which was greatly magnified by the rapid escape of 
the already carbonated portions that could issue through Botalli's 
opening, without returning to the aerating surfaces in the lungs. 
There was faulty injection by the heart. 

Such injection would lift the light valve of Botalli, whether from 
asynergy, or asynchronousness of the systole; and the consequence 
would be a state of partial asphyxia of the child, which is what is 
called cyanosis, morbus coeruleus, or blue-disease. 

In cyanosis, an irregular, imperfect, feeble innervative force will 
show itself in the muscular system of the child, whether animal or 
organic; and sudden convulsions, lipothymia, suspended respirations, 
and pulsations, with blue color more or less intense and extensive, 
will complete the picture of the maladive condition: the child will 
be affected with asphyxia more or less complete. If the respiratory 
sources in the cerebro-spinal axis are deluged with carboniferous 
blood to the extent of wholly suspending the biotic extrication — 
death is the consequence — sudden death. 

Cyanosis in this view, is asphyxia, greater or less, according to 
the intenseness of the cyanosis. 

But the question now recurs, as to what is asphyxia. In my 
opinion, asphyxia essentially considered, is black blood in the capil- 
laries of the brain. Some physicians insist that asphyxia is black 
blood in the lungs. I contend that asphyxia is black blood in the 
brain. Asphyxia is a state of the brain in which that organ can- 
not extricate, or give out the life-force — the innervative force — the 
stream or current of nervous force — the biotic force — and I contend 
that it fails to do so, for want of oxygen to react upon the neurine. 
Cyanosis is the sign of the presence of non-oxygeniferous blood, 
which is dark or purple or black blood, as Bichat calls it. This purple, 
or dark hue of cyanosis, is caused by the presence of black blood only 
in the capillaries. But, when this dark hue of the cutaneous capil- 
laries is seen, it is evidence of a similar hue of all the capillary blood, 



656 CYANOSIS NEONATORUM. 

whether in the abdominal, the thoracic, or the cephalic cavities and 
organs. This purple state of the blood is not fatal, except it exist 
in the brain, whose power it suspends. If it be chased out of the 
brain, by oxygeniferous streams of arterial blood, all the organs and 
tissues that lie under the control and dominion of the nervous system, 
immediately recover their power. If the brain dies, they all perish 
in its fall. If a man die, therefore, with asphyxia, he dies because 
he has black blood in the brain. 

A man may die from fainting, or lypothymia; and in this case he 
loses life, because the action of the brain is suspended. The sus- 
pension in this instance, appears to me to depend upon lessened tension 
of the encephalic mass from the sudden withdrawal of a portion of 
the blood that ordinarily distends its vessels, as in sudden violent 
hemorrhage, in certain pathemata mentis, rapid changes of posture, 
&c. &c. 

Asphyxia is lessened or suspended somatic innervation from pri- 
vation of the oxygen-reagent. Fainting is a similar suspension from 
reduced tension and pressure; either may be fatal; but each requires 
its appropriate treatment, which is different in each case. 

Asphyxia is essentially not a status of the trunk or members; it 
is a status of the brain, and only of the brain. The livid hue is a 
result or an accidence of the asphyxia. 

If the vessels of the brain be injected by the carotids and vertebrals 
with carboniferous blood, the intellectual, or perceptive, and the co- 
ordinating and motion-giving brains cease to do their office; if new 
injections fill these same vessels with oxygeniferous blood which 
chases out the former, the powers of the brain are reinstated, provided 
the mischief have not already gone too far. 

A man etherized, or affected with chloroform, is, to a certain extent, 
asphyxiated, besides being poisoned; the same is true of him, as of 
the well-digger, who descends into a well containing carbonic acid 
gas. The man in the well dies, not because his glottis is closed by 
spasm, as has been asserted, but because there is no oxygen in the 
well to be carried to the brain. It is indifferent to him whether his 
glottis be shut or open, since there is nothing to enter in that can 
do him good or harm; he dies from want of oxygen; and it may be, 
that the carbonic acid, if it enter his lungs, may do some mischief 
there; an indifferent mischief in the greater mischief. 

I said that asphyxia is black blood in the brain — not in the sinuses 
and veins of the brain, but in the capillary part of the vascular cyst 
of the brain. 






CYANOSIS NEONATORUM. 657 

The greater part of the whole amount of the blood, which is vari- 
ously computed to be about thirty pounds, exists in the systemic part 
of the vascular circle. Only a small portion of it is in the venous side. 
In the lungs, for example, where the pulmonary artery is a vein, 
and the pulmonary veins arteries, there is a great excess of the aerated, 
over the quantity of carboniferous blood, for not only is the capillary 
system full, but the venous system is full. But the carboniferous blood 
of the femorals, of the iliacs, of the portal, and the cava, produces no 
asphyxia; nor is it true that in death from carbonic acid inspired in 
a w T ell, the demise depends upon the presence of black blood in the 
trunk or members; it depends upon its presence in the brain, par- 
ticularly the respiratory, oxygenating brain, whose pneumogastric 
branches, and all other sources of respiratory innervation, are sus- 
pended and cut off indeed, because their neurine is flooded with car- 
boniferous blood in which there is no power to extricate the biotic 
force — the nervous force. 

If it be true that there is a valve on the left side of the auricular 
septum, it must be that its purpose is to prevent regurgitation of the 
blood from left to right. It could have no other use or design. 

Even in a case where greater power of the right auricle impels a 
portion of the black blood through the valved orifice, any resistance 
offered by the valve must tend to diminish* or prevent the transit from 
right to left. 

If in any such case the plane of the septum auricularum be ren- 
dered horizontal, by placing the child upon its right side, the blood 
of the left auricle must tend to close the aperture by pressing the 
valve down, and keeping it down. The blood has gravitation, and 
its law of gravitation is as rigorous in the auricle, as it would be in a 
cup, or in the air. Its weight must shut the valve, or tend to shut it, 
if any valve exist. But, with a shut valve, all the blood of the auricle 
must pass to the right ventricle, and so to the lungs to be aerated. But, 
if the blood becomes truly aerated, it becomes oxygeniferous, and 
transferring the oxygen to the capillaries of the brain, will there excite 
the biotic force in a normal manner. All the irregular and diseased 
innervations depending upon the antecedent carboniferous quality of 
the blood in the encephalic capillaries must vanish before the steady 
innervative streams that proceed from a healthy brain, duly supplied 
with its quantum of oxygen. 

There are many of my medical brethren w r ho deny that my expla- 
nation of cyanosis neonati is correct, or even philosophical; contending 
that cyanosis is a status of the lung, or of the vessels of the heart, 
42 



658 CYANOSIS NEONATORUM. 

bringing about a modality of the lung alone; or a backing of the 
blood into the whole venous side of the circle and a detaining of it 
in the capillaries; while I aver that the condition of the lung, or of 
the trunk and members, is nothing in the category, which relates, in 
fact, only to the state of the brain. 

I am quite conscious that a man's opinion cannot determine the 
least of Nature's laws to operate this way or that. St. Matthew tells 
us, " neither shalt thou swear by thy head, because thou canst not 
make one hair white or black." While, therefore, one gentleman 
sees only in a contracted pulmonary artery, or in a transposition of 
vessels, a cause of cyanosis, I am not to expect that he will come 
over to my way of thinking, because I think so, even had I the 
authority and power of the man of Pergamus, w 7 ho ruled us for fifteen 
hundred years. I am, however, less concerned to witness the ac- 
ceptation of my rationale, than the adoption of my precept. If they 
will turn the cyanosed neonatus upon its right side and shut down 
the auricular valve, I ought to be satisfied; and indeed, one dis- 
tinguished author, Prof. Wood, recommends the practice, while he 
dispraises the principle upon which it is founded. 

Nevertheless, I admit that I sincerely desire to find a reasoned ac- 
ceptation of my rationale ; less perhaps on account of its application 
to the undeniable self-demonstrating instances of blue-disease, than 
to the treatment of certain obscure, and more questionable forms of 
the accident. 

In order to explain my meaning more clearly, I shall relate a case 
that occurred to me a few years since, and upon which I put a con- 
struction that w r ill not be admitted by those who oppose my rationale 
of cyanosis, either as to its mechanism or its real nature. 

A lady had given birth to a child, apparently healthy. She was 
soon afterwards attacked with fever, wdiich produced in her a series of 
distressing nervous symptoms. The young child, after many days, 
became indisposed with what seemed to be a bronchial catarrh, w T hich 
W T as rebellious under the treatment. Dr. Bridges saw the child with 
me several times. It grew alarmingly ill. It was affected with a 
vast, troublesome collection of unexpectorated bronchial mucus, that 
threatened speedy suffocation by filling the air-tubes and trachea. 
Upon entering the apartment on one occasion, I found it in the arms 
of the monthly nurse, sorely oppressed and nearly insensible. It was 
dying — or, rather, I deemed it dying. 

My impression from inspecting the child was, that it was moribund ; 
and I still believe that the condition was that of the moribund, and 



i 



CYANOSIS NEONATORUM. 659 

that its life could not have been protracted beyond one or two hours, 
but for remedies employed to rescue it. 

After observing it for some time, and noticing a livid areola 
about its mouth, I took it from the nurse to inspect it more closely. 

The precise processes of thought by which I arrived at a conclusive 
opinion, have now escaped me; but I was led to imagine that the 
whole of the phenomena ought to be referred to a state of the brain, 
and not to a state of the bronchial mucous membrane. I supposed that 
the sources of innervation becoming modified by the presence of car- 
boniferous blood in the brain-capillaries, the organs had suffered in 
consequence of the cessation, or irregularity, of the administrative 
power. Upon cutting, in a surgical operation, certain branches of 
the trifacial nerve, the eye becomes instantly inflamed. Dr. J. 
Warren says that, under etherization, the conjunctiva is often injected 
with blood. The same thing occurs in ataxic fevers. So, in any 
hindrance of the current of the pneumogastric nerve-force, the lung 
might likewise become the seat of consecutive disorder. I was con- 
vinced that the child's foramen ovale admitted its venous blood to 
the systemic side of the circle, thus vitiating the biotic power of the 
nervous mass of the child. I turned it on its right side, and kept it 
there. In a few moments it was relieved, and in a very short time 
gave no further reason for alarm, or concern of mind. In fact, the 
right lateral decubitus cured it. 

In the month of January, 1846, I attended Mrs. H . . . . at the 
Indian Queen, South Fourth Street, in a confinement in which she 
gave birth to a healthy child. 

As she was ill many days with a fever, I gave but little attention 
to the child. It was between two and three weeks old, wdien I was 
summoned to it by three rapidly repeated messages. I found it in- 
sensible; affected at intervals of one to two minutes with convulsions, 
in which the head rotated to the right in strong extension; the right 
arm, stiffened, was elevated as strongly as possible by spasmodic 
innervation of the deltoid and triceps, while the left arm also stiffened, 
was pointed downward and outwards. The inferior extremities were 
also affected with rigid spasm. The mouth was open, and could not 
be closed, but by force. The pulse was feeble, and the respiration 
low T , except when troubled by the recurring spasm. Many persons 
surrounded the infant, which was on its back on a pillow, supported 
on the lap. 

The child had been well but a short time before. The attack had 
been a sudden one. 



660 CYANOSIS NEONATORUM. 

Upon contemplating the child, which had two or three attacks of 
this spasm or convulsion while I was looking on it, I reasoned with 
myself as to the probable cause. There was no assignable hygienic 
causation. 

Its mouth was bluish, though not in a very marked degree. 

I took the child on its pillow, and laid it on my knees, in order the 
better to inspect it. I reflected as follows : here is a faulty innerva- 
tion of the muscles of the head, neck, arms, legs, and lower jaw ; 
with suspended consciousness. Are the parts in fault, or is the brain 
in fault? whence these irregular intromissions of nerve-force ? Is the 
nervous mass imperfectly oxygenated because the child sends its 
carboniferous blood into the left auricle, and so to the brain ? 

I laid it on its right side in the cradle, its trunk elevated at about 
15°, and I said, "leave it in this position until I return. Perhaps it 
will die very soon ; but I have some reason to hope it may be saved, 
if you should not change its position. I shall be absent three hours. 
Do not venture to move it, until I come again." In the meantime 
while I remained, it changed its appearance speedily and visibly for 
the better; it had no return of the spasm. It fell into a calm sleep, 
and was perfectly well when it awoke. It required no further cure. 

Was this a post hoc, and not a propter hoc case? Who can say 
so? The treatment was reasoned beforehand, and the result looked 
for. 

As well might it be said that every therapeutical cure by emetics, 
cathartics, or narcotics, or diuretics, is a post hoc, and not a propter 
hoc cure. 

The blood in the auricle or ventricle, is not exempt from the laws 
of matter; it gravitates as absolutely there as in a teacup, or in the 
air. When I lay a child upon its right side, gravitation of the blood 
is inevitable ; and since the valve is as delicate as the arachnoid, the 
smallest drop resting upon it could close, as the slightest force could 
open it. 

I brought the plane of the septum auricularum to be a horizontal 
plane; I compelled the blood of the inferior cava to rise in a vertical 
current, to the fossa ovalis, and thus lessened the power of Eustachi's 
valve, to direct it upon the fossa ovalis. When I shut the valve 
down by the weight of the superincumbent blood, all the blood of the 
right auricle passed through the iter ad ventriculum, in order to be 
breathed upon in the lungs. It is probable that half a dozen systoles 
of the heart had scarcely been effected, before the oxygeniferous 
streams had reached the neurine, and waking into orderly and healthful 



CYANOSIS NEONATORUM. 661 

force, the before hebetized innervations of the child, all the dependent 
organisms and organs resumed their healthful movements and life- 
manifestations. 

Nov. 20, 1847, I was called to the child of Mr. H , in Pine 

Street below Eighth. This child, a female, was born in October, 
1847, and was now six weeks old. Upon reaching the rendezvous, 
I was pained to find the infant dangerously ill with catarrho-pneumonia, 
so far advanced, that I informed its mother it was probably too late 
to do it any great service. 

The bronchial tubes and the trachea were oppressed with a great 
quantity of mucus, which so obstructed the respiration, that the child 
coughed at every breath, which was very short, saccadee, and repeated 
sixty or seventy times per minute. Percussion and auscultation of 
the chest — careful examination of the abdomen — inquiries into the 
rate of the pulsations, both by feeling the radial pulse, and by aus- 
cultation of the heart, led me to the painful expectation that my 
friends were about to suffer the loss of their daughter. I prescribed 
for it, under the diagnosis of a catarrho-pneumonia. Some hours 
afterwards I repeated my visit. It was no better. 

Upon taking the child, which was on a pillow, and resting it on my 
knees, I found it in danger of suffocation. Every breath was that com- 
pound of coughing and crying, which I cannot describe, but which 
every physician has observed. Upon inspecting it, I observed a livid 
areola of the mouth. The feet were bluish, as well as the finger-nails. 
It is true that such blueness might depend, and did in part depend, 
on the saburral state of the pulmonary mucous membrane — smeared 
as it was with mucus, and the tubes partly filled up. As the attack 
had been sudden — too sudden to be conformable to the normal march 
of such maladies, I reflected that the fault might not be primary in 
the respiratory mucous membrane, or pulmonary texture, but in the 
brain, which had lost its power of maintaining the status sanitatis in 
the lungs. I deposited the infant on its side, as for the treatment of 
cyanosis neonati. It seems to me that the valve of Botalli fell down 
upon the foramen ovale, and that the carotid and vertebral injections 
of the brain immediately began to be thoroughly oxygeniferous. The 
administrative nervous mass commenced anew its government of its 
provinces, and, in a short time, the symptoms of the disease had 
vanished; I found in the morning of Nov. 21st, that no further treat- 
ment was necessary. I cured the broncho-pneumonia by shutting 
Botalli's valve, just as I should cure a conjunctivitis, by restoring the 
integrity of the trifacial branch cut off in a surgical operation on the 



662 CYANOSIS NEONATORUM. 

face, and the loss of whose innervative current might have determined 
the conjunctival inflammation. 

The objectors do not deny that the foetal circulation, up to the first 
act of respiration, is through the foramen ovale, and the arterious 
duct, and that it is so indispensably, and only because the operculum 
is raised. They cannot deny that the aperture virtually exists after 
birth, even for many days — nay, in some, during a long lifetime. 

To deny that the two zygozoar halves of the heart may act asym- 
metrically and asynchronously, is to deny an admitted truth. To 
deny the effect of such dissidence in time and force, appears to me 
to be but a mere denial. 

I had many years ago charge of the health of a young woman, who 
labored under frequent attacks of cyanosis. She was often threatened 
with sudden death. In the intervals she appeared to be in good 
health, earning her bread by the needle. 

One day, while much indisposed, she sat up in bed, eating a din- 
ner of codfish. She suddenly fell on her side dead, in her 28th year. 
I found a foramen ovale, into which I could put a swan-quill. 

In the heart of the Archduke Joseph, the cyanosis had coincided 
all his life long w T ith an open foramen ovale. — See Gintrac, p. 228. 

If in my own heart there be an aperture as large as the end of my 
finger, it is indifferent to me in respect of my health, while the two 
auricles contract symmetrically. But if asymmetrically, then I am 
liable to sudden illness, or even sudden death. My patient probably 
flooded her medulla oblongata with carboniferous blood, and ceased 
to breathe in consequence of the annihilation of biotic force evolved 
from the medulla. 

How often have we seen similar states of the system brought about 
in attacks of puerperal eclampsia ? 

In this disease, an impetuous sanguine circulation gives rise to un- 
measured, I had almost said explosive, evolutions of biotic force. In 
eclampsia, the spasm and convulsion of the whole system, and par- 
ticularly of the diaphragm, which often makes aspirations of only 
three or four cubic inches of air, allow the carboniferous streams to 
overflow the encephalon. Under this want of aeration, the face 
gathers blackness apace — the protruded tongue is of a deep purple, 
and a true asphyxia intervenes between the life and the death of the 
patient; so that the sooner the blackness of the features and tongue 
comes to assure us of the arrest of the cerebral excitation, the sooner 
is the patient to be extricated from her perilous predicament. 

If the medulla oblongata be overwhelmed, she dies ; sometimes 



CYANOSIS NEONATORUM. 663 

this is the case, and she dies outright, no trace of lesion being dis- 
coverable in the brain. 

Here we have no good and reliable sources of medication, save 
those that serve most rapidly and powerfully to diminish the momen- 
tum of the sanguine circulation in the encephalon, of which vene- 
section is to be before all others preferred. 

A proper venesection, executed before the asphyxia is established, 
in general prevents that consummation by substituting a state of 
deliquium for the otherwise inevitable asphyxia of the eclampsic 
paroxysm, a far less dangerous and more speedy way of escape: less 
dangerous, since the sanguine engorgements and retardations coinci- 
dent with the cyanosed state of the brain in eclampsia, expose the 
sufferer to inconvenient effusions or extravasation. 

As to the right lateral decubitus for the new-born child in cyanosis, 
no doubt rests on my mind, after multiplied experience since 1832, 
now sixteen years. I am not embarrassed by finding the treatment 
sometimes unsuccessful, because, when it is so, I can with confidence 
believe that failure to change the blood is effected through some other 
agency than that of an open and used foramen ovale. 

In the son of Mr. A. B , I detected the existence of cyanosis 

neonati, and relieved the child, but could not cure it by my method. 
A series of diseased innervations, bringing the whole constitution into 
ill-health, continued to manifest themselves, notwithstanding all the 
precautions I could devise, and I announced, long before the death 
of the infant, which lived for several months, in addition to a patent 
foramen ovale, the existence of an aperture in the septum ventri- 
culorum, which was verified by the examination of its heart after its 
decease. 

In a similar manner I announced in Mr. J. B 's child, an open 

foramen ovale, as the cause of convulsive attacks which led at last to 
an effusion within the encephalon with separation of the sutures, and 
evident fluctuation, which was verified necroscopically. 

Professor Wood will bear me witness of the sudden and marked 
and indubitable relief and cure of Mr. H. W 's infant, appa- 
rently dying with cyanosis, when it was placed in position. 

In the eldest son of Mr. S. B , jun., the respirations were but 

four to the minute ; the pulse was gone, and the child within two or 
three minutes of its death, nay, deemed by some to have breathed its 
last. The recovery was almost instantaneous. 

The same is true of Mr. H. K 's son, with the exception that 



664 CYANOSIS NEONATORUM. 

the case was not so extreme; so also of Mr. Rich's child, Mr. J. 
W 's, and many others. 

I beg leave to refer again to the letter from Prof. Eve, at p. 644, 
reciting a case of cyanosis treated by him. A letter from Dr. Casey, 
of Hartford, Conn., informs me of a violent case successfully treated 
by the position. Dr. Hains of this city, and many others, have suc- 
ceeded in like manner. Prof. Charles A. Lee, of Geneva College, 
informs me that the treatment is well known in Western New York. 

I can by no means adopt the views as to the essential nature of 
the malady, set forth in Prof. Wood's late work on the Practice of 
Physic. That author, like others, appears to me to have mistaken 
the symptom, to wit, the blue color, for the disease, which, as I have 
so often said, is essentially a failure of innervation from absence of 
oxygen in the brain. He doubts the causation as dependent on the 
mixture of the two kinds of blood in the heart. 

I cannot understand that the leg or arm should suddenly die for 
w r ant of oxygeniferous blood; and I cannot perceive how the consti- 
tution can live, if the nervous mass, which is the essential Ens, be 
dead, or inert, as it certainly is when only the carbonized blood of 
the veins circulates in its capillary vessels. M. Gintrac himself, who 
originally made four kinds or species of cyanosis — of which the first 
consists of the melange du sang noir et du sang rouge, and the se- 
cond a coloration bleue egalement constitute par ce melange— comes 
to the true conclusion at last, that, instead of four species, there is 
but one, although he calls that one two. 

Prof. Rokitansky, in his Patholog. Anatomie, vol. ii. Part I. p. 510, 
gives an article on cyanosis, in which he treats at large of the various 
kinds of that affection, whether as depending on faulty development 
of the heart, or on causes extrinsical as to that organ. He says, "a 
distinction is generally drawn between an organic disease of the heart 
acquired in the later periods of life, occasioned by disease of the lung, 
and that form of cyanosis dependent upon congenital malformation 
of the organ. The latter is called cardiac cyanosis. It will appear 
that the essential cause and character of both are the same. Cyanosis 
occurring in cases of congenital malformation of the heart has been 
mostly attributed to the mixture of the two kinds of blood, or rather 
to the passage of the venous blood into the arteries either by way of 
the ventricles, or the auricles, or the vessels themselves; but, it has 
been common to refer this commingling of the currents and the ac- 
companying symptom of cyanosis to a deficiency as to the septa of 
the heart. We are of the opinion that cyanosis always depends, not 



CYANOSIS NEONATORUM. 665 

upon the mixture of the two kinds of blood, which is, in many cases, 
problematical, and in some takes place in a directly opposite direction 
to w T hat is supposed, but on the impeded reflux of the venous blood 
into the heart and a consequent habitual, or, in some instances, inter- 
mittent engorgement of the venous and capillary systems ; and that 
herein all the varieties of cyanosis, however differing as to their 
original and acquired abnormal conditions of the heart and lungs, 
coincide, and may, without violence, be classed together." 

I shall not here reproduce all M. Rokitansky's arguments and 
statement of facts ingeniously brought to the support of this doctrine. 
I shall merely state that the opinions set forth in this chapter as to 
the consecutive nature or accidental nature of those contractions of 
the pulmonary and other orifices of the heart, appear to me undeniable, 
and that it is always reasonably to be expected that an uncured attack 
of cyanosis neonati w r illlead to a constriction of the pulmonary artery, 
just as the free expansion of the pulmonary artery, after the first as- 
pirations of the neonatus, leads to the abandonment of the ductus 
arteriosus and its early conversion into a ligamentum teres. 

Should this page be at some future day honored by the regard of 
that distinguished writer, the author would beg leave to direct his 
attention to the events and phenomena that occur in those cases in 
which a sudden coagulation of blood fills the right auricle and ven- 
tricles with a clot that is moulded by the cavities which it fills. Many 
examples are to be met with of these coagulations, some of which 
prove instantly fatal, wmile others admit of the prolongation of an 
ineffectual struggle for life during a period of from one to twenty days, 
according to my own clinical observation. 

Now in the instance of a cardiomorphous clot, as above proposed, 
the blood is most effectually detained in the venous side of the circle, 
far more so than can be hypothecated as of the intermittent forms of 
cyanosis, of which M. Rokitansky speaks. Yet as long as the patient 
continues to survive, he continues to thrust betwixt the outer super- 
ficies of the clot, or false polypus, and the inner walls of the auricle, 
tricuspid and ventricle, as well as the pulmonary artery, portions of 
blood that become thoroughly oxygenated in the lungs, for the re- 
spiratory effort is one of d esp eration, and the blood is probably 
charged to its very highest capacity with oxygen. It receives enough 
to maintain in the neurine the extrication of innervative force until the 
gradual augmentation of the clot cuts off the power of the circulation. 
In these cases the blue color, the cyanosis, the blaasucht, is scarcely 



666 CYANOSIS NEONATORUM. 

to be discovered, the patient being on the contrary ghastly pale and 
sunken. 

If Prof. Rokitansky and Prof. Wood's views are just, then we ought 
to have in the case of the pre-euthanasial clot the most striking example 
of the cyanosed state, for, when the heart becomes thus tamponed with 
a cardiomorphous coagulum, the whole of the venous side of the circle 
is stopped, and the black blood backed into the capillaries. A small 
endocardiac clot must have the same power to produce mechanical 
obstruction as contraction of the pulmonary artery; a large one is 
equivalent to a ligation of the cava. 

I deny not that a constriction of the pulmonary artery may pro- 
duce cyanosis. Whatever restricts the aclion of the venous heart, 
must do so. Great collections of fluid in the thorax produce it. 
Pressure upon the heart from dropsy of the pericardium ; extensive 
injuries of the lungs from tubercular degeneration ; suppurations, and 
large vomicse; cynanche trachealis, or pseudo-membranous laryngitis; 
pneumothorax; atelectasis pulmonum ; a host, indeed, of accidents 
and diseases that ruin or disable the respiratory machinery, may 
produce cyanosis. But of these I have not spoken. I confine my 
proposition to the persistent use of the foramen ovale after birth, a 
use in which the blood of the veins takes the course originally fol- 
lowed by that of the placenta. 

There is no other treatment for cyanosis neonati than that I have 
suggested ; at least, there is no other reasonable treatment. Vene- 
section, emetics, purgatives, diuretics, soporifics, baths, counter-irri- 
tants, cannot cure it. 

When cyanosis has introduced epiphenomenal affections, they may 
be treated. These affections will be found to relate chiefly to a state 
of the pulmonary circulation and excretions. 

In some instances, I have applied a large leech or two to the region 
of the heart, in order, haply, to assist in overcoming the pulmonary 
or cardiac engorgement, so apt to coincide with failure or disorder of 
the biotic power of the medulla oblongata. In general, however, 
when the malady has depended on the injection through Botalli's 
foramen, I have been content to place the infant in the proper posi- 
tion, and trust to that alone for the cure. 



SUPPLEMENTARY. 667 



CHAPTER XXV 



SUPPLEMENTARY. 



The introductory or prefatory letter, which is printed in the be- 
ginning of this volume, states that my vision has become much dis- 
ordered by a neuralgia, that has not only given me a great deal of 
pain, but has prevented me from being as accurate as I might per- 
haps have otherwise been in revising the proofs of this work. 

I find that at page 305 I have admitted a date (Aug. 1841), w T hich, 
though correct as understood of that date, is not to be taken as re- 
ferring to the present time, Feb. 1849. It is still true that I have not 
had occasion to regret one of those sudden demises after a good deli- 
very, in patients of my own. In one case that fell under my direction, 
I lost a patient in the hemorrhage that came on in a premature 
labor, and I was not only greatly shocked, but exceedingly surprised 
at the fatal result of a loss of blood, the quantity of w r hich did not 
appear to me to be sufficient to bring her life into great danger. After 
several gushes that took place before I could get the foetus away, 
she was very faint, and as she had long labored under an extreme 
degree of anaemia, I was aware that she could not well bear such great 
losses, as another or stronger woman might readily tolerate. 

Soon after one of the fainting-fits, she became uncontrollably rest- 
less and delirious, striving to get out of bed, and to sit up in it, the 
pulse uncountably frequent, and very small, the face being mean- 
while of a deathlike paleness. It required about half an hour of such 
a state of things to extinguish the last spark of existence, which 
termination occurred after heavy sighs, or efforts to respire. 

I wish the Student to reflect for a moment upon the above state- 
ment, and I ask him what explanation he can make or what rationale 
of the phenomena he can give better than the following hypothetical 
one, viz : 

The patient w T as anaemical. 

She flooded in the premature labor. 



668 PROLAPSE OF INTESTINES. 

The blood left in the vessels after the hemorrhage, was greatly in- 
creased as to its coagulability. 

She had deliquium. 

During the almost complete arrest of the circulation pending the 
deliquium, the blood in the right auricle became a clot. 

A clot once formed and become firm in the heart, can never be dis- 
charged. It is the nucleus upon which additional strata of coagula 
are imposed. It may grow rapidly or slowly larger. It may instantly 
or gradually fill the whole auricle, tricuspid valve, ventricle, and pul- 
monary artery. 

The convulsive action of the heart compresses the clot — all the 
haematoglobulin is expressed, leaving the mass a dull yellowish-white 
cardiomorphous polypus consisting chiefly of fibrine. 

The heart, if completely tamponed or plugged up in this manner, 
ceases to beat. Such an endocardiac clot is as fatal an accident as 
a bullet lodged in the cavity of the organ. I have seen several per- 
sons die in this manner. 



At page 462, I alluded to the case of Mrs. R., under the care of 
Dr. Bicknell, of West Philadelphia. It appears that I omitted to 
relate the case as I supposed I had done. It was as follows: 

Mrs. E,. was in violent labor, which had continued long, but without 
any effect. Dr. B. requested me to visit her with him. 

The vagina was pressed forwards towards the symphysis pubis, by 
a tumor behind it, filling up the excavation of the pelvis, and pre- 
venting the descent of the head. 

I learned by examination that this tumor consisted in a great mass 
of intestinal convolutions that had fallen down below the strait, and 
that was kept there by the violent tenesmus, as well as by pressure of 
the gravid womb above it. Indeed the mass was to a certain extent 
incarcerated within the excavation of the pelvis. The efforts of 
the patient to bear down upon her pains were most violent, and the 
distress accompanying them apparently intense. 

I introduced my fingers into the lower part of the vagina, and 
thrusting the posterior wall of that tube backwards, got the points of 
the fingers beneath the tumor, which occupied the recto-vaginal cul- 
de-sac of peritoneum. A little patient manipulation caused portions 
of the gut to ascend into the abdomen, and in a short time the whole 
mass fled upwards above the brim, whereupon the expulsive efforts 



bond's instrument. 



669 



of the womb being no longer opposed by it, the child was speedily 
and safely born. 



Before closing this volume, I wish to make the Student acquainted 
with the appearance and use of an instrument recently invented by 
Dr. Henry Bond, an eminent medical practitioner of this city, and 
which is designed for the purpose of restoring the womb to its proper 
situation in cases of its retroversion. 



Fig. 121. 




The instrument, of which I 'annex a figure, half size, (Fig. 121,) 
consists of two arcs of circles of different radii ; the inner one is 
terminated by a small oval piece of ivory; the outer terminates in a 
small ivory ball. The exterior arc is formed at its lower extremity 
into a plate-piece in which is a mortice ; to the end of the plate-piece 
is attached an ivory handle, by which it may be conveniently held. 
See the figure. The inner or smaller piece is attached to a sliding- 



670 

piece, also morticed, and overlapping by its edges the morticed plate- 
piece, and secured by a clamp or pinch traversing the mortices, and 
fastened or loosened by turning the thumb-piece. If the thumb-piece 
be unscrewed, the clamp may be turned lengthwise, and the arcs are 
then easily separated. 

In order to use the instrument, the arcs should first be separated, and 
the ivory ball on the largest arc introduced into the rectum, while the 
oval one on the smaller arc should be introduced into the vagina. 

By sliding the smaller arc upwards, the two balls can be placed 
opposite to each other; or the vaginal arc can be set a quarter of an 
inch, a half inch, or an inch lower down than the one that is in the 
rectum. 

Upon being adjusted, and firmly secured by turning the thumb- 
piece, it is manifest that the two balls cannot be separated from each 
other, and that if they be moved upwards, parallel with the curve 
of the sacrum to the height of the promontorium, they must carry the 
retroverted uterus before them, and thus serve very effectually and 
easily to reposit the dislocated organ. 

In a difficult case of retroversion, which I lately saw in consultation 
with Dr. Bond, I in vain made repeated attempts, in which I employed 
great perseverance and force, to get the retroverted fundus out of the 
peritoneal cul-de-sac, the bottom of which it had forced almost down 
to the vulva. In this case, Prof. Simpson's wornb-sound could not be 
made use of, on account of the position of the os uteri, which w T as 
quite as high as, and close to, the top of the symphysis pubis, and so 
firmly pressed against it as with difficulty to admit of reaching the os 
tincse with the indicator finger. I could by no means succeed in 
several attempts that I made, to introduce the probe point of Dr. 
Simpson's womb-sound into the os, for the canal of the cervix uteri 
made an acute angle with the posterior face of the symphysis pubis, 
and being in close contact with the top of the bone, it is clear that I 
could not introduce the top of the probe into it. I did bend the 
womb-sound near to its probe-point, so as to give it the shape of a 
blunt hook, and, introducing the hook within the os uteri, endeavored 
to draw the vaginal cervix down the symphysis, but I could not make 
it move, and was obliged to abandon the attempt. 

Upon the failure of these efforts, the caoutchouc bottles were made 
use of as pessaries, as recommended by M. Hervez de Chegoin, in 
the Mem. de PAcad. Roy. de Med. They doubtless served very use- 
fully to effect a partial elevation of the fundus; in the mean time the 
engorged uterus, whose length could not have been much less than 



I 



bond's instrument. 671 

five inches, became gradually less hypersemical, so that Dr. Bond was 
enabled, after three or four days, by means of the very ingenious in- 
strument whose figure I have here given, to lift the fundus out of its 
dislocated position, whereupon the unfortunate lady was immediately 
relieved of a most distressingly painful accident. 

A reviewer, in the January number of the British and Foreign 
Quarterly, treats Prof. Simpson, in my opinion, with uncalled-for seve- 
rity, on account of his womb-sound, of which I have above spoken. 
There is little danger to be apprehended of mischief resulting from 
the use of that beautiful instrument . in competent hands; and the 
facility with which an ordinary case of retroversio uteri may be re- 
lieved by it, together with the absolute safeness of its application, in 
the proper cases, are qualities so very valuable, and the whole opera- 
tion is so much less disquieting to the fastidious patient, than the ordi- 
nary methods of treatment, that I think the profession should feel in 
the highest degree indebted to Dr. Simpson for his admirable invention. 
As to the uses of it in diagnosis, it appears to me, since I have 
become acquainted with it, that it is an indispensable article in the 
apparatus of the physician and surgeon. 

And now, that I have come to write the last paragraph of this 
volume, I take occasion to bid the Student God speed in his arduous 
path, to exhort him so to direct his course, that he may elevate him- 
self to the highest rank of the Scholar-class, by which alone he can 
hope to reap the only and true reward of a life spent in the service 
of them that are in pain, in fear, or in danger of death. I beg leave 
to assure him that he can never know too much of the opinions and 
experience of mankind, gained during the lapse of ages, on the subject 
of Disease and its Remedies. 



INDEX. 



Abdomen, 168 
Abortion, 211 

causes of, 211 
ergot to produce, 593 
Dr. Lee's case, 593 

hemorrhage during, 213 
treatment of, 216 

instruments in, 211 

Puzot on, 216 

symptoms of, 211 

tampon in, 216 
Abscess of labium, 79 

of mamma, 603 
Accoucheur, 17 

conduct of, 245 
Acephalous foetus, 193 
Adherent placenta, 29S 

in hour-glass contraction, 392 
After pains, 303 

confounded with peritonitis, 565 
Alimentation of the child, 618 

artificial, 623 
Allantois, ISO 
Allantoidal space, 183 
Alvine evacuations of the child, 626 

management of, 627 
Alvus, 284 
Amenorrhcea, 12S, 135 

cautions in regard to, 129 

causes of, 135 

diet in, 146 

treatment of, 137 
Amnion, 155 
Amussat, 227 
Anasmia, 142, 414 

as cause of amenorrhea, 135 
preternatural labor, 414 
cases, 414, 417 
Anasmia gravidas, 207, 419 

case, 419 
Anaesthesia, 315 

objections to, 411 

Prof. Simpson's letter on, 319 
reply to, 322 
Analysis of healthy blood, 119 

of menstrual fluid, 119 
Anencephalous foetus, 193 
Antagonism of corpus and cervix uteri, 162 
Anus, artificial in infant, 183 
Aphthae, 630 

treatment, 631 
Application of obstetric forceps, 492 

difficulties in, 494 

precautions in, 495 

rules for, 490 

43 



Arm, prolapsed, 371 

Collins on, 371 
cut off, 373 
torn off, 

prosecution for, 372 
Arnold, Dr. Frederick, 17 
Asdrubali, Prof., 196, 480 
Asphyxia, 187 
Atelectasis pulmonum, 610 
Atresia vaginae, 583 
causes, 583 
case of, 583 
simulated, 586 
case of, 586 
Auricular ligaments, 26 
Auscultation, obstetric, 239 
Average duration of labor, 279 
Dr. Churchill's table on, 279 
Dr. Collins on, 279 
Axis of the pelvis, 46 



E 



Bachman, Rev. Dr., 159 
Bag of waters, 256 
Ballottement, 239 
Bar bone, 25, 36 
Barry, Martin, 96, 153 
Baudelocque, 46, 249, 269, 489, 508, 574 
forceps, 481 
the younger, 574 
Bearing down, 255 
Belly-band, 625 
Bernhardt, 100 
Biberon, the, 619, 624 
Bichat, 179 
Binder, 310, 390 

necessity for, 311 
case, 310 
Births, 

most frequent at night, 248 
Quetelet on, 248 
Villerme on, 248 
Buck on, 249 
Bischoff, 101, 108, 153 
Bladder, the, 48 

depressed in labor, 289, 462 

case, 289 
distended, 220 

as cause of retroversion, 220 
case, 222 
Blastoderm, 179 
Blaud's pills, 145 
Blood, healthy, 

analysis of, 119, 415 
anaemical, 415 



674 



INDEX. 



Blood, 

menstrual, 119 
Boivin, Mad., 118, 270, 278, 341 
Bond, Dr. Henry, 215, 669 
Bourgeois, Louise, 380 
Breech presentations, 346 

not dangerous to mothers, 346 
fatality of, to child, 346 

diagnosis of, 348 

conduct of, 350 

1st position, 352 

2d position, 354 

3d position, 355 
case, 355 

4th position, 357 
cases, 358 

fillet in, 439 

forceps in, 506 
Bremser, 208 
Breschet, 155, 177 
Brierre de Boismont, 119 
Bright's case, 608 
Broad ligaments, 39 
Brugnone, 194 
Buck, Dr., 249 
Burdach, 104, 179 



Caduca, 154 
Cesarean section, 

Simpson's case, 456, 513 

when demanded, 508 

the mother's operation, 508 

Mrs. R.'s case, 530 
Carcinoma uteri, 

as cause of preternatural labor, 427 
cases, 427 
Carus, 17, 47 

curve, 47, 294 
Case, 

difficult, of embryotomy, 513 

Dr. Lee's, of ergot to produce abortion, 
593 

Depaul's, of early detection of sounds of 
fcEtal heart, 242 

of absence of uterus, Renauldin's, 129 

of artificial rotation, 358 

of breech labor, 3d position, 355 

of Cesarean section twice performed, 
531 

of cephalic version, 364 

of complicated milk-fever, 597 

of compressed intestine during labor, 
426, 668 

of concealed pregnancy, 241 

of cyanosis, Dr. Eve's, 644 
Dr. Irwin's, 643 
Dr. Schreiner's, 645 

of death from sitting up too soon, 308 

of depressed bladder, 289 

of difficult face labor, 284 

of ectopy, 193 

of Elizabeth Sherwood, 509 

of false pains, 262 

of fatal uterine hemorrhage, 306 

of forced evolution, 376 

of forceps rotation, 462 

of hysterical dyspncea, Bright's, 608 



Case, 

of induction of premature labor, Dr. 

Lee's, 539 
of laceration of perineum, 497 
of laceration of uterus, 466 

Mauriceau's, 466 
of mammary abscess, 607 
of Mauriceau's sister, 396 
of Mrs. E., 540 
of Mrs. R., 509, 513, 539 
of narrow pubic arch, 293 
of obliquity of the uterus, 296 
of obliteration of vagina, 583 
of oedema gravida?, 421 
of relaxation of pelvic symphyses, 58 
of retroversion in the virgin, 225 

with pregnancy, 227 
of rigid os uteri, 284 
of simulated atresia vagina?, 586 
of sixth position of the vertex, 58 
of spasmodic closure of the womb, 202 
of tumor in pelvis during labor, 464, 668 
of turning for hemorhage, 445 

Cases, 

of absence of uterus, 130, 131, 132 

of anaemia gravidae, 417, 419 

of angulation of the intestine, 578 

of atresia vaginae, 583, 586 

of breech presentation, 4th position, 358 

of carcinoma uteri, 428 

of cramps during labor, 29, 30 

of convulsions, 407, 408, 409 

of cyanosis, 641, 643, 644, 645 

of difficult face labors, 334,338, 339, 340 

of extra-uterine pregnancy, 236, 237 

of gastric disturbance during pregnancy, 

165 
of hemorrhage, 304, 305 

of successful use of ergot in, 306, 
307 
of inverted uterus, 547 

of spontaneous replacement of, 550, 
551, 552 
of monstrosity, 189 
Clarke's, 189 
Pfeiffer's, 189 
Serres', 188 
Rohrer's, 194 
of procidentia uteri, 85 
of prolonged gestation, 196, 197 
of retroversion, 221, 225, 227 
of slow pulse during labor, 282 
of use of the binder, 310 
of vomiting during pregnancy, 165 

Catamenia, 116 

Causardine, M., 476 

Cautions, 279, 281, 295 

Cavity of the womb, 162 

Cazeaux, 348, 588 

Cephalodym, case of, 192 

Cerise, Dr., his theory, 650 

Cervix uteri, 87 

antagonism of, with fundus, 162 
carcinoma of, 427 
dilatation of, 256 
management of, during labor, 291 
rigid, 284 

Chailly, M., 203 

Chamberlen forceps, 469 — 479 
Hugh, 471 



i 



INDEX. 



675 



Chamberlen, 

Mauriceau on, 471 
Paul, 470 

Hugh's, preface, 473 
Chang and Eng, 437 
Change of life, 116 
Chapman, Samuel, 479 
Child, 

alimentation of, 618 

rules for, 621 
causes of death in utero, 186, 611, 612 
danger of, in breech presentations, 346 
to preserve, in do do 364 

danger of, from use of ergot, 689 
dress of, 615 
during labor, 267 
history and diseases of, 610 
how to treat, after delivery, 296 
length of, 67 
still-born, 613 
washing of, 615 
weaning of, 622 
weight of, 67 
Child's head, 61 
bones of, 62 
sutures of, 62 
diameters of, 45, 63 
fontanels of, 64 
Child-bed fever, 558 
Chloroform, 317 

Prof. Simpson's letter on, 319 

reply to, 322 
Duncan and Flockhart's formula for, 321 
medicinal effects of, 320 
Chorion, the, 155 

Churchill, Dr., 17, 279, 434, 508, 542 
Circulation, 

in the fetus, 184 
in the placenta, 175 
of the female in labor, 281 
Circumcision of the female, 78 
Clarke's case of monstrosity, 189 
Clarke, Dr., of London, 280 
Classification in obstetricy, 18 
Clitoris, the, 78 
anatomy of, 79 
absent in the Didelphis, 78 
DeGraafon,78 
Miiller on, 79 
hypertrophy of, 79 
Coagulation of the blood in the heart, 308 
Cohesion of the labia, 75 
nymphs, 77 
sides of the vagina, 583 
Collins, Dr., 205, 348, 368, 370, 384, 40 1 , 403, 
404, 503, 571 
letter on puerperal fever, 592 
Colombat, 77 
Colostrum, 620 
Computation of term, 199 

Nsegele on, 199 
Concealed hemorrhage, 389 
Conception, 150 
definition, 150 
Hippocrates on, 150 
Galen on, 150 
Conduct of a labor, 278 
cautions in, 278, 281 

cases, 282 
definition, 278 



Conduct of a labor, 

Dr. Clarke on, 280 

Rainald on, 279 

prognostic in, 280 

venesection in, 183 
Contractions of womb, 

hour-glass, 299, 392 

painless, 170 

ergotic, 589 
Convulsions, puerperal, 401 
Cord, the, 183 

around the neck, 295 

dressing of, 615 

knots in, 187 

length of, 183 

not to be pulled, 299 

prolapse of, 414 

tying of, 613 
Corpus luteum, 105 

identity of with yelk of egg, 105 
Coryza, 632 

cause of death from, 634 

treatment, 635 
Cosgreave, P., 373 
Coste, M., 90, 95, 100, 156 
Costiveness during pregnancy, 169 
Cosal bones, 32 
Cramps during labor, 29, 412 

causes, 29 

during pregnancy, 169 
Crupper bone, 31 
Cuckoo bone, 31 
Cuvier, 19, 78, 123 
Cyanosis, 184, 637 

causes, 637 

Rokitansky on, 665 

Wood on, 669 



Davis, Dr. David, 17 

forceps of, 482 
Decapitation of the fetus, 611 
Decidua, 154 

vera, 155 

reflexa, 155 

Breschet on, 155 

Hunter on, 155 

Coste on, 156 
Decubitus during labor, 283 

dorsal, when necessary, 283 
case, 284 

in puerperal fever, 579 
Deformed pelvis, 452 

causes, 452 

classification, 459 

examination of, 459 

forceps in, 457 

specimens, 453 

turning in, 457 

relative frequency in U. S. and Europe, 
510 

embryotomy in, 513 

Cesarean section in, 509 
De Graaf on clitoris, 78 

on ovaries, 96 
Deliverance, 177 
Delivery, 

of the shoulders, 295 



676 



INDEX. 



Delivery of the shoulders, 295 
mechanism of, 53 

of the placenta, 297 
womb after, 302 

artificial, frequency of, 362 
Lachapelle on, 362 
Denis, 119 
Denman, 17, 53S 
De Paul,' M. 

on obstetric auscultation, 240 

early detection of foetal heart, 243 
Depressed bladder, 462 

case, 289 
Development force, 112 

a generical force, 112 

a genetic force, 112 

of the foetus, 171 
Deventer. 17 
Dewees, 253, 215, 233, 450, 5SS 

error of, 337 
Diameters of foetal head, 45, 63 

pelvis, 44 
Didelphis Yirginiana, 73, 158 

anatomy of, 155 

pregnancy in, 159 
Diet,' 312 
Digestive apparatus, 

disturbed during pregnancy, 166 
Dimensions of pelvis, 44 

mode of ascertaining, 450 
Diseases of foetus in utero, 157 
Distended bladder, 220 

causing retroversion, 220 
Doctrine of menstruation, 123 
Dressing the child, 615 

the cord, 615 
Dubois, P., 345 
Ductus arteriosus, 611 

afterbirth, 611 
Duncan and Flockhart's formula for chloro- 
form, 321 
Duration of pregnancy, 193 

in quadrupeds, 199 

Painard-'s statistics on, 194 

Brugnone ; s do 194 

Earl Spencer's do 194 

Grille- s do 195 

Tessier's do 194 

Winter's do 194 



Eclampsia, 205 
Ectopv, 193 
Edwards, Milne, 208 
Egs, human, 103 
Emansio mensium, 134 
Embryo, 

circulation of, 161 

position of, in utero, 163 

early, 151 
Embryotomy, 511 

auscultation before, 511 

implements employed in, 511, 515 

in exhaustion, 512 

in locked head, 505 

in deformed pelvis, 513 

mode of performing, 512 

Mrs. R. ; s case, 513, 531 



Embryotomy, 

when impracticable, 514 

forceps, 525 
Emmenagogues, 138 
Endangium, the, 141, 143 
Endangitis, 561 
Epidemic influence, 565 
Ergot, 588 

constitutional effects of, 592 

dangers of use of, 559 
"to child, 590 

Dewees on, 555 

effects of, 559 

James on, 555 

in post-partum hemorrhage, 307, 3S0. 
592 

in abortion, 593 

Michel on. 555 
Eschricht, 174 
Etherization, 315 
Eustachian valve, 1S4 
Evolution, 

Cosgreave's plan, 373 

compelled, 375 
case of, 376 

Pfeiffer's case, 375 

Rohrer's, 375 

spontaneous, 374 
Excavation, the, 22 
Exhaustion, 421 

causes, 422 

embryotomy in, 512 

forceps in, 999 

symptoms, 423, 424 
Exomphalos, 153, 625 
Extra-uterine pregnancy, 236 

cases, 236, 237 



Fabricius ab Aquapendente, 174 
Face presentations, 59, 327, 332 
only two positions of, 332 
mechanism of, 59 
management of, 60, 334 
Dewees on, 333, 337 
diagnosis of, 334 
cases, 334, 339, 340 
prognosis of, 341 
Boivin on, 341 
Lachapelle on, 341 
sugillation after, 343 
forceps in, 503 
Fainting, 404 
Fallopian tubes. 55 
False pains, 260 
causes, 260 
diagnosis, 261 
case, 262 
' Fecundation, 115, 149 

vegetable, Schleiden on, 149 

ovaric, 115 
only during ovi-ponte, 123 
' Feet, to distinguish, 360 
Female, circumcision of, 78 

torso, profile of, 41 
Fever, puerperal, 553 

milk, 594 
Fifth position, 57 



INDEX. 



677 



Fillet, the, 436 

when to be used, 436 
mode of using, 436 
First position, 

of the vertex, 51 

of the right shoulder, 448 

turning in, 44S 
of the left shoulder, 449 

turning in, 450 
of pelvic presentation, 70, 532 
of the face, 332 
Flexion, 51 

in labor, 268 
to assist, 2S7 
Flourens, 10S, 111, 173, 1S1, 318, 325 
Foetal head, measurements of, 45 

bones of, 62 

sutures of, 62 

diameters of, 63 

to grasp, 468 
heart heard during pregnancy, 240 

structure of, 184 
Foetus, human, 

development of, 171 
acephalous, 193 
anencephalous, 193 
causes of death of, 187 
circulation in, 184, 611, 638 
decapitation of, 511 
diseases of, 188 
monstrous, 188 

cases, 189 
position of, in utero, 183 
of the whale, 176 
Fontanels, 64 

diagnosis of, 65 
Foramen Botalli, 184 
at birth, 611 

premature closure of, 185, 611 
Forceps, obstetric, 467 
inventor of, 468 
importance of, 467 
Chamberlen's, 476 

description of, 477 
Dr. Samuel Chapman on, 479 
old curve, 479 
new curve, 480 
Haighton's, 479 
Mulder's history of, 480 
Asdrubali on, 480 
Smellie's, 480 
Levret's, 480 
Pean's, 481 
Baudelocque's, 481 

his experiments, 488 
Davis' obstetrical, 482 
Siebold's, 483 
Huston's, 483 

description of the instrument, 481 
the child's instrument, 486 

not a compressor, 487 
handle to handle movement, 488 
designed for the head, 490 
rules for using, 490 
difficulties in using, 494 
precautions in use of, 495 
manner of extraction with, 496 
removal of, before delivery, 497 
to effect rotation, 498 
with vertex in hollow of sacrum, 500 



Forceps, obstetric, 

in occipito-posterior positions, 501 

with transverse head, 501 

in face presentations, 503 

in locked head, 505 

in deformed pelvis, 457 

placental, Dr. Bond's, 215 
Forehead, application of forceps to, 505 
Fossa navicularis, 81 
Fourchette, the, 81 
Fox, Dr. Geo., 512 



G 



Galen, 152 
Gardien, 17 
Gastrotomy, 

in ruptured uterus, 467 
Geburt, die des menschen, 40, 247, 275 
Gendrin, 17 
Generation, 150, 171 

organs of, 71 
Genitalia, 3 
Germ, the, 114 

extrusion of, 114 
Germinal vesicle, 699 
Gestation, 193 

duration of, 193 

prolonged, 196 

cases of, 196, 197 
Asdrubali's case, 196 
Merriman's case, 196 

tendency to menstruate during, 127 

ovulation during, 126 
Gibson, Prof., 530 
Gifford, 17 
Gintrac, quoted, 642 
Gordon, Alexander, 558 
Graafian follicles, 93, 103 

cell, 103 
Granular membrane, 95 
Gravid uterus, 

appearance of, 201 

Smellie on, 201 
Grille, M., 195 
Guiette, Dr., 24S 
Guillemeau, 17 
Gum, the, 629 



Hsematosis, 141 
Haighton's forceps, 479 
Haller, 118, 546 
Hardening the child, 617 
Hatch, Dr., case, 552 
Head, foetal, 

measurement of, 45, 63 N 

flexion and obliquity of, 51 

rotation of, 52 

extension of, 53 

restitution of, 53 

bones of, 62 

sutures of, 62 
Head, transverse, 

forceps in, 501 

locked, forceps in, 503, 504 
Heart of foetus, 610 



678 



INDEX. 



Hemorrhage, uterine, 303 

care in examination in, 303 
causes, 304 
cases, 304, 305 

from rising suddenly, 306 
case, 306 

post-partum, 390 

ergot in, 307, 380, 592 

coagulability of blood after, 308 

unavoidable, 999 

treatment of, 379 

before labor, 383 

concealed, 399 

precautions against, 394 

Mauriceau's case, 396 

tampon in, 396 

in abortion, 213 

treatment of, 216 
Hemorrhagic labor, 377 

causes, 377 

management, 378 
Henle, 107 
Hermaphroditism, 79 
Hernia, 414 
Hey, 558 
Hip bones, 32 
Hippocrates, 68, 152 
Hodge, Prof., 230 
Home, Sir E., 151 
Hooper's pill, 143 
Horner, Prof., 229 
Hour-glass contraction, 204, 299, 302 

causes, 299, 300, 392 

treatment, 302, 393 
Human egg, 103 
Hunter, John, 169 

William, 177 
Huschke's views, 101, 104, 114 
Huston, Prof, 30 

forceps of, 483 
Hydatid degeneration of the ovum, 207 

Milne Edwards on, 208 

Pouchet on, 208 

nature of, 208 

diagnosis of, 209 

treatment of, 209 
Hydrometra, 210 
Hymen, the, 80 

imperforate, 81 

simulating atresia, 586 

no test of virginity, 81 
Hypertrophy of the clitoris, 29 



Icterus, 632 
Impregnation, 

liability to, 128 
Induction of premature labor, 538 

history of, 538 

dangers of, 540 

in vomiting of pregnancy, 166 

in deformed pelvis, 538 
Dr. Lee's case, 539 

Letter to Dr. E. on, 540 
Inversion of the womb, 

causes of, 546 

spontaneous, 550 



Inversion of the womb, 
complete, 546 
cases, 547 
mode of reduction, 548 
Mr. White on, 549 
incomplete, 546 

treatment of, 550 
prognosis in, 657 
Inverted womb, 

spontaneous replacement of, 551 
Dr. Moehring's case of, 557 
Dr. Levis' case of, 551 
Dr. Hatch's case of, 552 
Mr. Cross on, 556 
Iron in amenorrhea, 144 

Que vermes, 145 
Irritable breast, 602 
Ischial planes, 24 



James, Prof., 308, 336, 395, 588 
Jaundice, 632 
Jewish laws, 128, 153 

opposed to fruitfulness, 152 
Jewish women, 128, 153 

after delivery, 277 

after menstruation, 128 
Jews, laws of, 28, 152 

population of, 152 
John Ocularius, 246 
Joints, pelvic relaxation of, 38 

case, 38 
Jones, T. Wharton, 100, 108 
Jb'rg, 17 



Kelly, Dr. C, 161 



Labia pudendorum, 72 

majors, 72 

minora, 75 

diseases of, 73 

cohesion of, 75 

differences of, 76 
Labial thrombus, 73 

abscess, 74 
Labor, 245 

definition of, 245 

time of commencement of, 249 

nature of, 249 

cause of, 250 

Baudelocque's theory, 251 

caution as to prognostic in, 257 

constitutional effects of, 256 

outward signs of, 257 

the child in, 267 

flexion of the head in, 268 

mechanism of, 272 

completion of, 274 

conduct of, 278 

unassisted, proportion of, 278 

average duration of, 279 

circulation in, 282 



INDEX. 



679 



Labor, 

venesection in, 283 

anaesthesia in, 315 

pain in, physiological, 328 

hemorrhagic, 377 

retarded, 699 

preternatural, 361 
Labors, 

most frequent at night, 248 
Labor pains, 91, 245 

cause of, 252 

number of, 81,252 

duration of, 252 

dilating, 253 

expulsive, 254 

false, 260 

periodicity of, 263 

effects on bladder and rectum, 253 

effects on constitution, 254, 256 

actions of woman during, 255 
Laceration of womb and vagina, 464 

most frequent seat of, 464 

symptoms of, 465 

signs of, 466 

conduct of, 465 

case of, 466 

gastrotomy in, 467 
Lachapelle, Mad., 270, 342, 362 
Lactiferous ducts, 596 
Lady Webster's pill, 143 
Laennec, 208 
Lamotte, 17 
Lawrence, Mr., 78, 85 
Lee, Robert, 17, 108, 458, 539, 558 
Legallois, quoted, 650 
Letheby, 120 
Levatores ani, 49 
Levret, 17, 489 

forceps of, 489 
Liebig, Prof., 161 
Ligamenta rotunda, 49 

during pregnancy, 170 
in retroversion, 171 

lata, 49 

during pregnancy, 170 
Ligaments of the pelvis, 36 
Linea ileo-pectinea, 22 
Lochia, 275, 276, 314 
Locked head, 503 

forceps in, 505 

embryulcia in, 505 

above the superior strait, 450 
Longings, 167 
Lowenstein, 17 
Lower pelvis, 22 



M 



Macauley, Dr., 538 

Macula germinativa, 95, 101, 117 

Mammary abscess, 603 

causes, 603 

evils of, 604, 605 
case, 607 

treatment of, 603, 605 

weaning in, 609 
Mammary glands, 594 

anatomy of, 595 
Haller on, 596 



Mammary glands, Haller on anatomy of, 596 

during pregnancy, 595 

after delivery, 596 

suspension of, 604 
Martin Barry, 96 
Mauriceau, 17 

case of his sister, 396 

his account of Hugh Chamberlen, 471 

preface of Chamberlen to his work, 473 
Maygrier, 108 
Measurements of the pelvis, 23, 45, 63 

foetal head, 45 
Mechanism of the pelvis, 51 

of labor, 51 

of the shoulders* delivery, 53 

of 1st position of vertex, 53, 272 

hip, 272 

rotation, 273 

extension, 274 

restitution, 275 

of 2d position of vertex, 54 

of 3d do do 55 

of 4th do do 56 

of 5th do do 57 

of 6th do do 57 

of face, 59 
Meconium, 625 
Medicine, 313 
Membrana granulosa, 95 
Menagoga, 135 
Menstruation, 116 

age of commencement of, 116 

of cessation of, 116 

appearances of, 121 

ovary after death during, 121 

doctrine of, 123 

during pregnancy, 213 

duration of, 117 

nature of, 118, 122 

period of, 1 16 

precautions during, 116 

retardation of, 134 

synonymes of, 116 

suppression of, 135 

total absence of, 129 
Menstrual discharge, 116 

amount of, 116 
Menstrual fluid, 

nature of, 118 

Haller on, 118 

Boivin on, 119 

Brierre de Boismont's analysis of, 119 

Rindskopf's do 120 

Simon's do 120 

Letheby's do 120 

Merriman, Dr., 199 
Method, 19 
Michel on ergot, 588 
Midwife, 17 
Midwifery, 17 

meddlesome, 278, 325 
Milk, 

when secreted, 597 
Milk fever, 594 

symptoms, 597 

nature of, 597 

complications of, 597 
case, 597 

dangers of, 598 
Milk fistula, 607 



680 



INDEX. 



Miscarriage, 211 

Moles, 210 

Mollities ossium, 17 

Monsters, 1SS 

Serres' case, 1S8 
Pfeiffer's case, 189 
Clarke's case, 189 
Hohrer's case, 189 
nature of, 191 

Mons veneris, 72 
diseases of, 72 

Montgomery, Dr., 108 

Moreau, 108, 203 

Morsus diaboli, 88 

Mueuet, 631 

Mulder, Dr., 480 

Miiller, J., 7S, 117 

Murphy, Prof. Ed. W., 476 

Muscles, uterine, 202 
arrangement of, 203 
Chailly on, 203 
Moreau on, 203 
contraction of, 203 



X 



Naegele, Prof., 17, 199, 272, 453, 454, 455 
Nature, periodicity in, 123 
Navel, management of, 624 

pouting of, 169 
Navel string, 625 

division of, 275 

not to be pulled, 299 

tying of, 614 

dressing of, 615 
Needham, Walter, 183 
Negrier, 118 
Nipple, 

structure of, 596 

excoriated, 599 

ointment for, 600 

artificial, 602 
Nasud-vital, 31S 
Noortwyck, 179, 183 
Nymphas, 76 

diseases of, 77 

coherent, 77 



Obliquely deformed pelvis, 453 

management of cases, 453 
Obliquity of the uterus, 244 

to correct, 28S 
Obstetrician, 17 
Obstetricy, 17 
Obstetric auscultation, 239 

value and importance of, 240 
case, 241 

as ground for prognosis, 356 

before embryotomy, 511 
Occipito-posterior positions, 

forceps in, 501 
OZdema labiorum, 73 

gravidarum, 206, 420 

treatment of, 420 

Puzot on, 206 
Oken, Prof., 140, 160, 330 



Omphalo-mesenteric vessels, 1S2 
Opening of the joints, 3S 
Opossum, 78 

anatomy of genitalia of, 15S 

pregnancy in, 159 
Organs of generation, the, 71 
Os coccygis, 31 

pectinis, 35 
Ossa pubis, 26, 33 

innominata, 32 

ischia, 43 
Os uteri, 

management of, during labor, 291 

undilated, 291 

to render dilatable, 372 

rigid, 373 

anaesthesia in, 373 

rigid in placenta prsevia, 384 
Dr. Collins on, 384 
Ovarian follicles, 93 

pregnancy, 152 

Pouchet on, 154 
BischofF on, 154 
Martin Barry on, 154 
Ovaric fecundation, 115 
Ovaries, the, 93 

absence of, 129 

Barry on, 96 

Bernhardt on, 100 

Bischoffon, 101 

Burdach on, 104 

Coste on, 95 

De Graaf on, 96 

Dumas on, 100 

development of, 97 

effects of removal of, 130 

functions of. 114 

Huschke on, 104,114 

influence of, on character of female, 112 

office of, 114 

Purkinje on, 97 

Von Baer on, 98 

Wagner on, 95 

Wharton Jones on, 100 
Ovarium, 

Coste's views on, 101 
Oviposit,. 114 

fecundation only during, 12S 
Ovisacs, 94 
Ovulation, 126 

and deposit, 144 

during pregnancy, 213 
Ovulum, 100 

maturation of, 104 
Ovum, human, 103 

of the bitch, 100 
Owen, Prof., 159, 173 



Painless contractions of the womb, 170 
Pare, 17 

Patterson, Dr., 108 
Pean's forceps, 481 
Pelvic joints, 36 

relaxation of, 38 
case, 3S 

presentations, 344 

causes of, 345 



INDEX. 



681 



Pelvic joints, 

diagnosis of, 348 
dangerous to the child, 346 
why ? 347 

fatalities in, 34S 

not preternatural, 345 

frequency of, 344 
Bland on, 345 
Boivin on, 345 
Collins on, 345 
Lachapelle on, 345 
Merriraan on, 345 
Naegele on, 345 

forceps often necessary in, 355 
application of, in, 506 

Rainald on, 346 

positions of, 70 
Pelvis, 21 

synonymes of, 21 

axis of, 46 

diameters of, 44 

dimensions of, 44 

mode of ascertaining, 459 

deformed, 453 

ligaments of, 36 

measurements of, 23, 44 

mechanism of, 51 

nerves of, 49 

recent, 48 

anatomy of, 49 

the whole of, 39 

tumors in, 462 
case, 463 

vessels of, 49 
Pelvimeters, 460 
Pennsylvania Hospital, 

anaesthesia in, 322 
Perineum, the, 81 

structure of, 81 

in labor, 82, 274, 293 

to relax, 293 

to support, 293 

influence of on mechanism, 58 

convex in the old, 49 

laceration of, 83, 498 

cicatrices of, 83 

in forceps operations, 497 
Periodicity, reproductive in nature, 123 
Peritoneum, the, 49 

extent of, 561 

inflammation of, 558 
Pfeiffer, Dr., case of monstrosity, 184 
Physick, Dr., 601 
Physometra, 201 
Pill, Hooper's, 143 

Lady Webster's, 143 

Blaud's, 145 
Placenta, 

adherent, 299, 393 

circulation in, 175 

connection of with uterus, 176, 178 

cotyledons of, 176 

delivery of, 297 

description of, 180 

expulsion of, 177, 267, 276 

function of, 161, 174 

foetal surface of, 175 

maternal surface of, 175 

human, entirely foetal, 172 

Hunter on, 172 



Placenta, 

Fabricius on, 174 
Flourens on, 173 
Owen on, 173 
Seiler on, 172 
Velpeau on, 172 

removal of, before the child, 387 
forceps, Dr. Bond's, 215 
hook, Dewees', 215 
Placenta praevia, 382 

symptoms of, 382 

cause of hemorrhage in, 383 

prognosis of, 3S4 

turning in, 3S4 

ergot in, 386 

comparative frequency of, 386 

Collins on, 386 
Mauriceau on, 386 
Simpson's treatment of, 387 
Radford's do 387 

Placental souffle, 239 

tufts, 174 
Plane of the superior strait, 39 
inclination of, 39 
of the inferior strait, 43 
form of, 45 
Planes of the ischia, 24, 34 
Plethora, 142 
Position, 

definition of, 69 
Positions of the breech, 352 
of the vertex, 51, 70, 269 

mechanism of, 51, 57, 272 
how produced, 268 
relative frequency of, 268 
Baudelocque on, 269 
Naagele on, 269 
Simpson on, 269 
Boivin on, 279 
Lachapelle on, 270 
Post-partum hemorrhage, 790 
nature of, 390 
concealed, 391 
treatment of, 391 
Pott, Percival, 130 

Pouchet, 108, 109, 122, 128, 152, 208 
Poupart's ligament, 23 
Pouting of the navel, 169 
Pregnancy, 147 

definition of, 148 

commencement of, 151 

computation of, 127 

duration of, 193, 249 

signs of, 164, 238 

diagnosis of, 168 

development of womb during, 162 

auscultations in, 237 

vomiting of, 165 

costiveness of, 169 

cramps of, 169 

headache of, 205 

vertigo of, 205 

convulsions of, 205 

cough of, 205 

swelled feet of, 206 

varicose veins of, 206 

menstruation during, 233 

concealed, 241 

vaccination during, 432 

after inversion, 551 



682 



INDEX. 



Pregnancy, 

with permanent retroversion, 227 

protracted, 196 

Asdrubali on, 197 

ovarian, 152 

Bischoff on, 154 
Martin Barry on, 154 
Pouchet on, 154 

tubal, 153 

extra-uterine, 236 
Premature labor, 

induction of, 166, 638 
Presentations, 65 

only two, 65 

pelvic and cephalic, compared, 26 

cephalic, 68 

deviated, 68 

pelvic, 69, 344 
deviated, 69 

relative frequency of, 67 

face, 327 

mechanism of, 69 

shoulder, 363 
Pressure of the womb on the vessels, 204 
Preternatural labor, 361 

definition, 361 

causes, 361 

relative frequency of, 362 

from anaemia, 999 

from carcinoma uteri, 427 
cases, 428 

from compressed loops of intestine, 426 
case, 426 

from convulsions, 401 

from cramps, 29, 412 

from deformed pelvis, 452 

from depressed bladder, 462 

from exhaustion, 421 

from fainting, 414 

from hernia, 414 

from placenta prsevia, 382 

from prolapse of the cord, 412 

from prolapse of a mass of intestines, 
462 

from small-pox, 430 

from tumors, 462 

from twins, &c, 435 

from vaginal vesicocele, 289 

from want of flexion, 463 

from want of rotation, 463 
Prevost and Dumas, 102 
Primipars, 

more liable to convulsions, 204, 404 
Procidentia uteri, 85 

Mr. Stanley's case, 85 

Dr. Hains' case, 85 
Professional conduct, 245 

Wigand on, 247 

during labor, 279 

Rainald on, 279 

Dr. Clarke on, 280 
Profiles of the female torso, 41 
Prognosis, 

cautious in labor, 257 

auscultation as ground of, 358 
Prolapse of the cord, 412 

effects of, 412 

management of, 412 
Prolapsus uteri, 85 

in pregnancy, 164, 219 



Promptness, necessity for, 444 

cases, 445 
Puberty, 140 

age of, 116 
Pubic arch, 24 

deformity of, 461 
Pubis, 34 

arch of, 35 

symphysis of, 35 

ramus of, 235 

faulty, 292, 461 
cases, 292 
Pudenda, 12 

Puerperal convulsions, 401 
causes, 401 
Collins on, 401, 403 

generally in primiparae, 404 
Clarke on, 404 
Collins on, 404 
Merriman on, 440 

prevention of, 402 

symptoms of, 405 

treatment of, 405 

consequences of, 408 
cases, 407, 408 
Puerperal fever, 558 

causes, 559 

symptoms, 560, 567 

diagnosis, 565 

pathology of, 561 

precautions against, 569 

tympanites of, 576 

angulation of intestine in, 578 

prognosis of, 580 

non-contagious, 567 

treatment of, 578 

venesection, the cure of, 568 

M. Baudelocque on, 574 

Dr. Collins on, 571 
letter on, 581 
Purkinje, 97 
Purkinjean vesicle, 78 
Puzos, 206, 216 
Pythagoras, maxim of, 257 



Quetelet, M., 248 
Quevenne's iron, 145 
Quickening, 167 

definition, 167 

causes, 167 

in a medico-legal point of view, 168 

as a sign, 242 



Raciborski, 108, 145 
Rachitis, 453 
Radford, Dr., 387 

Rainald, Thomas, 279, 325, 346, 366, 467 
Rainard, M., 194 
Randolph, Dr., 589 
Recto-vaginal septum, 81 
Removal of the placenta, 
before the child, 387 
arguments for, 387 
against, 388 



INDEX. 



683 



Renauldin, Dr., 129 

Reproductive periodicity in nature, 123 

organs, influence of on the constitution, 
164 
Restitution, 53 
Retained placenta, 298 
Retarded labor, 

by obliquity, 288 

by rigid os uteri, 291 
perineum, 293 

by faulty sacrum, 291 
pubis, 292 
Retroversion of the womb, 171, 220 

causes, 171, 220 

cases, 221, 222 

treatment, 224 

cured by catheter alone, 224 

in the virgin, 224 
case, 224 

permanent, 227 

with pregnancy, 227 

Dr. Yardley's case, 227 

Amussat's case, 227 
Revaccination during pregnancy, 433 
Rheumatism of the womb, 139 

in labor, 260 

Wigand on, 260 

diagnosis of, 260 

case, 262 
Rigby, Dr., 272 
Rindskopf, 120 
Rita-Christina, 189, 437 
Rohrer's case, 190 
Rokitansky, 665 
Rosenmuller, 94 
Rotation, 52 

to assist, 287 

forced, 463 
case, 463 

to effect by forceps, 498 
in breech cases, 498 
Round ligaments, 49 

during pregnancy, 170 

in retroversion, 171, 221 
Rupture of the membranes, 

in hemorrhage, 380 

of the uterus, 464 
Ruysch, 299 



S 



Sacral nerves, 28 
Sacro-iliac junction, 32 
Sacro-vertebral angle, 32 
sciatic notch, 34 
ligament, 34 
Sacrum, 27 

faulty, 291, 462 
deformed, 462 
promontory of, 32 
Scholar, influence of the, 247 
Schleiden, 149 
Schwann, Thomas, 107, 109 
Secale cornutum, 588 
Second position, 

of vertex, 54 

of right shoulder, 448 

of left shoulder, 449 

of pelvic presentation, 70 



Second position, 

of the face, 333 
of the breech, 354 
Seiler, 172 

Serres' views, 188, 309 
Sex, 112 
Sharp crotchet, 526 

objections to, 526 
Shear-bone, 53 
Shoulder presentation, 363 

causes of, 363 

diagnosis of, 364 

turning in, 366, 447 

right positions of, 448 

left positions of, 449 
Shoulders, 

mechanism of delivery of, 272, 295 
Siamese twins, 188 
Siebold's forceps, 183 
Sigault, M., 508 
Sigaultian section, 507 

condemned, 508 
Signs of pregnancy, 164, 238 

often overlooked, 238 

rational, unreliable, 239 

physical, 239 
Simon, Franz, 120 
Simpson, Prof., 272, 369, 387, 456, 458 

letter from, 319 
reply to, 322 
Sitting up, 314 

too soon, 307 
Sixth position, 57 

case, 58 
Skull-cap in coryza, 636 
Small-pox in pregnancy, 431 
Smellie, 201 

forceps of, 480 
Snuffles, the, 632 
Solayres, 513 
Sore mouth, 630 

treatment, 631 

nipples, 599 

treatment of, 600 

Dr. Physick on, 601 

pommade for, 601 
Spencer, Earl, 195 
Spigelius, 196 
Spontaneous evolution, 373 

nature of, 374 
Stanley, Edward, 85 
Stein, 17 
St. Hilaire, 190 
Strait, superior, 22, 25 

plane of, 39 

deformed, 455 

inferior, 25 
Stroma, 94 
Strophulus albidus, 630 

intertinctus, 630 
Subsidence of the womb, 251 
Suckling, 313 
Sue, M., 507 
Suppressio mensum, 134 
Swan, Dr., 108 

Swelled feet of pregnancy, 206 
Symphyseal ligaments, 36 
Symphyseotomy, 507 
Syncope, 305 

cause, 305 



684 



INDEX. 



Syncope, 

after hemorrhage, 305 
danger of, 308 



Tablier des Hottentots, 78 

Lawrence on, 78 

Merat on, 78 

Cuvier on, 78 
Tache embryonaire, 95 
Tampon, the 

in abortion, 217 

in hydatids, 203 

when inadmissible, 218 
never, 309 

danger of, 219 
Tenesmus, 255 

to prevent, 221 
Teratological fetuses, 189 
Tertullian, 469 
Tessier, 195 
Third position of vertex, 55 

mechanism of, 55 

of pelvic presentation, 70, 354 
Thrombus of labium, 73 
Tonics, 144 
Touching, or examination, 258 

object of, 258 

mode of proceeding, 259 
Transcendental anatomy, 203 
Transverse head, 

forceps in, 501 
Tubal pregnancy, 153 
Tumors in the pelvis, 463 

during labor, 463 

management of, 463 

proposal to puncture, 463 
Dr. Beesley's case, 464 
Tunica granulosa, 95 
Turning, 363, 386, 440 

Rainald on, 366 

time for, 367 

preparation for, 367 

mode of performing, 368, 442 
Collins on, 368 
Simpson on, 368 

to know when completed, 369 

difficulties of, 370 

engagement of the head during, 442 

after treatment, 370 

in placenta pragvia, 385 

in 2d vertex position, 446 

in 3d do do 446 

in 4th do do 447 

in 5th do do 447 

in shoulder presentations, 447 

in deformed pelvis, 457 
Simpson on, 458 
Lee's cases, 458 
Turn out the clot, 310 
Twins and triplets, 434 

relative frequency of, 434 
Churchill on, 434 

signs of, 434 

delivery of, 435 

placenta? of, 437 

chorion of, 437 

amnion of, 437 



Twins and triplets, 

development of, 191 
locking of heads of, 436 
danger of hemorrhage, 451^ 

Tympanitis of puerperal fever, 577 



U 



Umbilical cord, 182 
length of, 183 
knots in, 187 
composition of, 175 
ring, closure of, 625 
Umbilical vesicle, 181 

arteries and veins, 182 
retraction of, 625 
Unassisted labors, 

proportion of, 278 
Boivin on, 278 
Urachus, 181 
Ureters, 49 
Urethra, 79 

diseases of, 80 
Uterine muscles, 202 
Uterus, the, 87 

structure of, &c, 88 
lining membrane of, 89 

Coste on, 89 
fibres of, 89 

Chailly on, 90 
spasm of, 90 
absence of, 129 

cases, 130, 132 
dimensions, 162 
at term, 170 
weight of, 162 

after labor, 162, 275 
gravid appearance of, 201 

Smellie on, 201 
obliquity of, 204 
pressure of, in vessels, 204 
during menstruation, 125 



Vaccination during pregnancy, 432 
Vagina, the, 48, 84 

influence in prolapsus, 85 

follicles of, 86 

structure of, S6 

laceration of, 464 
Vaginal vesicocele, 

in labor, 289 
Vagitus uterinus, 276 
Valentine, Dr., 108 
Vallet's mass, 144 
Valve of Botalli, 611 
Varicose veins, 206 
Velpeau, 17, 172, 556 
Venesection, 

during labor, 283 
Dewees on, 283 
object of, 283 
evils of, 283 
when demanded, 283 
Version, 440 

by the head, 441 
Vestibulum, 79 



INDEX. 



685 



Viability, 610 
Villerme, 248 
Vital triangle, 416 
Vitellary matter, 

identity of with corpus luteum, 105 
nature of, 106 

Carpenter on, 106 

Bernhardt on, 106 

Bischoff on, 108 

Henle on, 107 

Huschke on, 107 

Schwann on, 109 

Von Baer on, 108 

Miiller on, 106 
Vitelline aac, 1S2 
Vomiting of pregnancy, 165 

causes, 166 

treatment, 166 

cases, 165 
in beginning of labor, '257 
Von Baer, 98, 108 
Vulva, 72 



W 



Wagner, Rudolph, 79, 95, 101 
Wakley's experiments, 325 
Weaning, 622 

in mammary abscess, 609 
Weber, 174 
Weed, 602 
Whale, fetus of, 176 
Wigand, Justus Henrich, 40, 247, 275 



Wind pregnancy, 210 
Winter, Simon, 204 
Womb, the, 87 

structure, &c, 81 

how sustained in the pelvis, 88 

rheumatism of, 139 

development of, during pregnancy, 162, 
200 

antagonism of cervix and fundus of, 162 

painless contractions of, 170 

examination of, at term, 178 

prolapsion of, 85 

during pregnancy, 219 

retroversion of, 220 

with pregnancy, 227 

subsidence of, 281 

after delivery, 302 

power of contracting, 370 

laceration of, 464 

inversion of, 546 
Women, non-menstruating, 129 
Wood, Prof, 663, 664, 665, 666 



Yelk ball, 94 
Yardley, Dr., case, 227 



Zona pellucida, 95 



THE END. 






E 90 6® 







m am 



